Basic Information
| Provider Information | |||||||||
| NPI: | 1326021171 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUKSAVONG | ||||||||
| FirstName: | BOUNLATH | ||||||||
| MiddleName: | KENT | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 737 W CHILDS AVE | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953406805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093831848 | ||||||||
| FaxNumber: | 2093831296 | ||||||||
| Practice Location | |||||||||
| Address1: | 847 W CHILDS AVE | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953416862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093837441 | ||||||||
| FaxNumber: | 2093831643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2005 | ||||||||
| LastUpdateDate: | 11/20/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA12844 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1022633 | 01 | CA | NCCPA CERT # | OTHER | MS0488759 | 01 | CA | DEA CERT | OTHER |