Provider Demographics
NPI:1033516265
Name:KHAMPHILAVONG, BRITTANY (PA)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:KHAMPHILAVONG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 960482
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0482
Mailing Address - Country:US
Mailing Address - Phone:855-686-8430
Mailing Address - Fax:904-265-8181
Practice Address - Street 1:1701 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8911
Practice Address - Country:US
Practice Address - Phone:337-494-3000
Practice Address - Fax:904-265-8181
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant