Individual
MINDY BACCAM SOUTHAMMAVONG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
405 MONROE ST, PELLA, IA 50219-1189
(641) 621-2200
(641) 621-2335
Mailing address
405 MONROE ST, PELLA, IA 50219-1189
(641) 621-2200
(641) 621-2335
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
078982
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
078982
IOWA LICENSE
IA
01
—
1528434859
NPI NUMBER
IA
Enumeration date
08/20/2015
Last updated
05/01/2017
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