Basic Information
| Provider Information | |||||||||
| NPI: | 1184607285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOON | ||||||||
| FirstName: | PHANTHAVONG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RN, CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 HUEBNER RD | ||||||||
| Address2: | |||||||||
| City: | FORT RILEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664424030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852397000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 650 HUEBNER RD | ||||||||
| Address2: | |||||||||
| City: | FORT RILEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664424030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852397000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 202201644RN | OR | N | Nursing Service Providers | Registered Nurse | 163W00000X | 14-153121-072 | KS | N | Nursing Service Providers | Registered Nurse | 163W00000X | 0001186892 | VA | N | Nursing Service Providers | Registered Nurse | 367500000X | 43-557812-072 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 24179395 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.