Provider Demographics
NPI:1356321384
Name:VILAYSANE, KETSANA (MD)
Entity Type:Individual
Prefix:
First Name:KETSANA
Middle Name:
Last Name:VILAYSANE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6183 N FRESNO ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-8611
Mailing Address - Country:US
Mailing Address - Phone:559-432-5003
Mailing Address - Fax:559-432-5008
Practice Address - Street 1:6183 N FRESNO ST STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8611
Practice Address - Country:US
Practice Address - Phone:559-432-5003
Practice Address - Fax:559-432-5008
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA84750207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI22609Medicare UPIN