Provider Demographics
NPI:1356336515
Name:NOLA, BOUNSAVATH (MD)
Entity type:Individual
Prefix:DR
First Name:BOUNSAVATH
Middle Name:
Last Name:NOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 S BLUFFVIEW DR STE 116
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-3039
Mailing Address - Country:US
Mailing Address - Phone:316-689-6004
Mailing Address - Fax:316-613-2934
Practice Address - Street 1:1431 S BLUFFVIEW DR STE 116
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-3039
Practice Address - Country:US
Practice Address - Phone:316-689-6004
Practice Address - Fax:316-613-2934
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-24718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSF70174Medicare UPIN
KS104201Medicare ID - Type Unspecified