Healthcare Provider Details

I. General information

NPI: 1356321384
Provider Name (Legal Business Name): KETSANA VILAYSANE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6183 N FRESNO ST STE 101
FRESNO CA
93710-8611
US

IV. Provider business mailing address

6183 N FRESNO ST STE 101
FRESNO CA
93710-8611
US

V. Phone/Fax

Practice location:
  • Phone: 559-432-5003
  • Fax: 559-432-5008
Mailing address:
  • Phone: 559-432-5003
  • Fax: 559-432-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA84750
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: