Basic Information
| Provider Information | |||||||||
| NPI: | 1033516265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAMPHILAVONG | ||||||||
| FirstName: | BRITTANY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960482 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556868430 | ||||||||
| FaxNumber: | 9042658181 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 OAK PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374943000 | ||||||||
| FaxNumber: | 9042658181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2014 | ||||||||
| LastUpdateDate: | 08/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA200771 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.