Provider Demographics
NPI:1063456184
Name:XAYSANASY, PHETSAMONE PETER (DPM)
Entity Type:Individual
Prefix:DR
First Name:PHETSAMONE
Middle Name:PETER
Last Name:XAYSANASY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W SUNBRIDGE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-1899
Mailing Address - Country:US
Mailing Address - Phone:479-251-9200
Mailing Address - Fax:
Practice Address - Street 1:125 W SUNBRIDGE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1899
Practice Address - Country:US
Practice Address - Phone:479-251-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR193213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR14086717Medicaid
AR14086717Medicaid
AR5L630Medicare PIN