Provider Demographics
NPI:1457308967
Name:KAMTHONG, SASIWAN W (FNP)
Entity Type:Individual
Prefix:
First Name:SASIWAN
Middle Name:W
Last Name:KAMTHONG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:122 W JOHN CARPENTER FWY STE 420
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2014
Mailing Address - Country:US
Mailing Address - Phone:972-957-3000
Mailing Address - Fax:972-957-3005
Practice Address - Street 1:2636 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-6485
Practice Address - Country:US
Practice Address - Phone:972-487-5800
Practice Address - Fax:972-487-9680
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP111202363L00000X, 363LF0000X
TX614334363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147897601Medicaid
P44706Medicare UPIN