Provider Demographics
NPI:1760960462
Name:KEOMANIVONG, SID CHRISTIAN
Entity Type:Individual
Prefix:
First Name:SID
Middle Name:CHRISTIAN
Last Name:KEOMANIVONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3344 WINTERHAVEN ST
Mailing Address - Street 2:UNIT 101
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-5064
Mailing Address - Country:US
Mailing Address - Phone:702-343-0466
Mailing Address - Fax:
Practice Address - Street 1:2677 BEALL LN
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-1462
Practice Address - Country:US
Practice Address - Phone:702-343-0466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201806379NP-PP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care