Healthcare Provider Details

I. General information

NPI: 1548164692
Provider Name (Legal Business Name): SOULIYO PHETSOMPHOU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: YO PHETSOMPHOU

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 MONTGOMERY DR
SANTA ROSA CA
95405-4801
US

IV. Provider business mailing address

1776 STILLWATER PL
SANTA ROSA CA
95403-8512
US

V. Phone/Fax

Practice location:
  • Phone: 707-525-5300
  • Fax:
Mailing address:
  • Phone: 808-782-9224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95223927
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: