Provider Demographics
NPI:1790330850
Name:KEOVILAY, PHOUDONG (PA-C)
Entity Type:Individual
Prefix:
First Name:PHOUDONG
Middle Name:
Last Name:KEOVILAY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3947 RANCHO REINA CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3572
Mailing Address - Country:US
Mailing Address - Phone:559-430-5280
Mailing Address - Fax:
Practice Address - Street 1:18300 CA-18 1ST FLOOR
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-242-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant