Provider Demographics
NPI:1497061170
Name:LATA, LAMPHOUN (PTA)
Entity Type:Individual
Prefix:
First Name:LAMPHOUN
Middle Name:
Last Name:LATA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5921 SE 14TH ST STE 2000
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50320-1728
Mailing Address - Country:US
Mailing Address - Phone:515-965-5311
Mailing Address - Fax:515-965-5301
Practice Address - Street 1:5921 SE 14TH ST STE 2000
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50320-1728
Practice Address - Country:US
Practice Address - Phone:515-965-5311
Practice Address - Fax:515-965-5301
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001442225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA001442OtherN/A