Healthcare Provider Details

I. General information

NPI: 1891282554
Provider Name (Legal Business Name): AIRNOI N/A PHONGSAVATH LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 E CARTWRIGHT AVE
FRESNO CA
93725-9385
US

IV. Provider business mailing address

3133 N MILLBROOK AVE
FRESNO CA
93703-1425
US

V. Phone/Fax

Practice location:
  • Phone: 559-498-7100
  • Fax:
Mailing address:
  • Phone: 559-394-9628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number293096
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: