Active NPI
Phokham Mike Sourivanh, PA-C
- Medical Physician Assistant
- Pensacola, FL
National Provider Identifier
1972022762
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Medical Physician Assistant
- Practice address
- Nmrtc Pensacola 6000 West Highway 98
Pensacola, FL 32512-0001 - Phone
- (901) 874-6081
- NPI assigned
- Sep 13, 2017
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Military Health Care Provider | 171000000X | |||
| Medical Physician Assistant | 363AM0700X | Primary |
Addresses
Primary practice location
Nmrtc Pensacola 6000 West Highway 98
Pensacola, FL 32512-0001
Mailing address
Camp Pendleton
Apo, AP 92055
Other practice location 1
34800 Bob Wilson Dr
San Diego, CA 92134-1098
Phone (619) 532-6400
Other practice location 2
Camp Pendleton
Apo, AP 92055
Phone (760) 725-1288
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1505260800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1750723200000",
"number": "1972022762",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "MIL",
"address_1": "CAMP PENDLETON",
"city": "APO",
"state": "AP",
"postal_code": "92055"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "NMRTC PENSACOLA 6000 WEST HIGHWAY 98",
"city": "PENSACOLA",
"state": "FL",
"postal_code": "325120001",
"telephone_number": "901-874-6081"
}
],
"practiceLocations": [
{
"address_1": "34800 Bob Wilson Dr",
"address_purpose": "LOCATION",
"city": "San Diego",
"state": "CA",
"postal_code": "921341098",
"country_code": "US",
"telephone_number": "619-532-6400",
"country_name": "United States",
"address_type": "DOM"
},
{
"address_1": "Camp Pendleton",
"address_purpose": "LOCATION",
"city": "APO",
"state": "AP",
"postal_code": "92055",
"country_code": "US",
"telephone_number": "760-725-1288",
"country_name": "United States",
"address_type": "MIL"
}
],
"basic": {
"last_name": "SOURIVANH",
"first_name": "PHOKHAM",
"middle_name": "MIKE",
"name_prefix": "Mr.",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2017-09-13",
"last_updated": "2025-06-24",
"certification_date": "2025-06-24",
"status": "A"
},
"taxonomies": [
{
"code": "171000000X",
"taxonomy_group": "",
"desc": "Military Health Care Provider",
"state": null,
"license": null,
"primary": false
},
{
"code": "363AM0700X",
"taxonomy_group": "",
"desc": "Physician Assistant, Medical",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Pensacola, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.