Individual
BOUNLATH KENT SOUKSAVONG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
847 W CHILDS AVE, MERCED, CA 95341-6862
(209) 383-7441
(209) 383-1643
Mailing address
737 W CHILDS AVE, MERCED, CA 95340-6805
(209) 383-1848
(209) 383-1296
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA12844
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1022633
NCCPA CERT #
CA
Enumeration date
11/25/2005
Last updated
03/07/2023
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