Basic Information
Provider Information
NPI: 1003294737
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SIRIKANJANAPONG
FirstName: SASIS
MiddleName:  
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Credential:  
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Mailing Information
Address1: 189 SCHERMERHORN ST APT 3A
Address2:  
City: BROOKLYN
State: NY
PostalCode: 112016097
CountryCode: US
TelephoneNumber: 9179436997
FaxNumber:  
Practice Location
Address1: 4802 10TH AVE
Address2:  
City: BROOKLYN
State: NY
PostalCode: 112192916
CountryCode: US
TelephoneNumber: 7182837154
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/14/2015
LastUpdateDate: 06/19/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
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IsSoleProprietor: Y
IsOrganizationSubpart:  
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AuthorizedOfficialCredential:  
NPICertificationDate: 06/19/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
282N00000X277589NYN HospitalsGeneral Acute Care Hospital 
207ZP0101X277589NYY Allopathic & Osteopathic PhysiciansPathologyAnatomic Pathology

No ID Information.


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