Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 68031 | GA |
Y | 208600000X | Surgeon | 68031 | GA |
N | 2086S0102X | Surgical Critical Care | 068031 | GA |
NPI | 1225281330 |
---|---|
Provider Name | Bounthavy Homsombath |
First Address | Augusta, GA 30914-3726 |
Second Address | Augusta, GA 30909-1868 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2008 |
Last Update Date | 18/05/2021 |