Provider Demographics
NPI:1295447548
Name:PHEANG, PANIDA (NP-C)
Entity type:Individual
Prefix:
First Name:PANIDA
Middle Name:
Last Name:PHEANG
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GROTON RD
Mailing Address - Street 2:
Mailing Address - City:AYER
Mailing Address - State:MA
Mailing Address - Zip Code:01432-1168
Mailing Address - Country:US
Mailing Address - Phone:978-784-9328
Mailing Address - Fax:978-784-9666
Practice Address - Street 1:200 GROTON RD
Practice Address - Street 2:
Practice Address - City:AYER
Practice Address - State:MA
Practice Address - Zip Code:01432-1168
Practice Address - Country:US
Practice Address - Phone:978-784-9328
Practice Address - Fax:978-784-9666
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2296859363LG0600X, 363LX0106X, 363LA2200X, 363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health