Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 193 | AR |
Y | 222Z00000X | Podiatrist | 193 | AR |
NPI | 1063456184 |
---|---|
Provider Name | Dr. Phetsamone Peter Xaysanasy |
First Address | Fayetteville, AR 72703-1899 |
Second Address | Fayetteville, AR 72703-1899 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2006 |
Last Update Date | 03/01/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
14086717 | (05) | AR |
U82695 | (02) | AR |