MEDICARE: BOUNLATH KENT SOUKSAVONG PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA12844	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1022633	OTHER	CA	NCCPA CERT #

General Provider Information

NPI Number	:	1326021171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BOUNLATH KENT SOUKSAVONG PA

Provider Business Mailing Address
First Line	:	737 W CHILDS AVE
Second Line	:
City	:	MERCED
State	:	CA
Zip	:	95340-6805
Country	:	US
Telephone Number	:	209-383-1848
Fax Number	:	209-383-1296

Provider Business Practice Location Address
First Line	:	847 W CHILDS AVE
Second Line	:
City	:	MERCED
State	:	CA
Zip	:	95341-6862
Country	:	US
Telephone Number	:	209-383-7441
Fax Number	:	209-383-1643

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/25/2005
Last Update Date	:	03/07/2023

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