Provider Demographics
NPI:1619222874
Name:PHANTHAVONG, SOUKSAVANH LISA (PA-C)
Entity Type:Individual
Prefix:
First Name:SOUKSAVANH
Middle Name:LISA
Last Name:PHANTHAVONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SOUKSAVANH
Other - Middle Name:LISA
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4001 LONG PRAIRIE RD STE 125
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1532
Mailing Address - Country:US
Mailing Address - Phone:972-539-3030
Mailing Address - Fax:972-539-3037
Practice Address - Street 1:4001 LONG PRAIRIE RD STE 125
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1532
Practice Address - Country:US
Practice Address - Phone:972-539-3030
Practice Address - Fax:972-539-3037
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07876363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant