Provider Demographics
NPI:1447909346
Name:DEDTHANOU, PHONPHANH (DO)
Entity type:Individual
Prefix:
First Name:PHONPHANH
Middle Name:
Last Name:DEDTHANOU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 RED MULBERRY WAY APT 2
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25306-6317
Mailing Address - Country:US
Mailing Address - Phone:515-779-4571
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:1310 HSC
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-293-2342
Practice Address - Fax:304-293-7725
Is Sole Proprietor?:No
Enumeration Date:2022-03-20
Last Update Date:2022-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program