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NPI Code Detail

MEDICARE: DISA XAYAVONGSONE NP

MEDICARE: DISA XAYAVONGSONE NP
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
1363LP0808XPsychiatric/Mental Health Nurse Practitioner404954NY
2163W00000XRegistered Nurse743043NY

General Provider Information

NPI Number : 1487427886
Entity Type Code : Individual
Provider Name (Legal Business Name) : DISA XAYAVONGSONE NP
Provider Business Mailing Address
First Line : 107 INSTITUTE ST
Second Line :
City : JAMESTOWN
State : NY
Zip : 14701-6628
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 107 INSTITUTE ST
Second Line :
City : JAMESTOWN
State : NY
Zip : 14701-6628
Country : US
Telephone Number : 716-484-4334
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/07/2023
Last Update Date : 03/02/2026

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