Basic Information
| Provider Information | |||||||||
| NPI: | 1982667333 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUNKEUA | ||||||||
| FirstName: | PHOUMY | ||||||||
| MiddleName: | BOBBY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 900 | ||||||||
| Address2: | 2321 WEST DAYTON AIRPORT ROAD | ||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985840974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604264433 | ||||||||
| FaxNumber: | 3604274654 | ||||||||
| Practice Location | |||||||||
| Address1: | 2321 W DAYTON AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985846319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604264433 | ||||||||
| FaxNumber: | 3604274654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 01/07/2013 | ||||||||
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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 | 363A00000X | 2514 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8373490 | 05 | WA | MEDICAID |