Provider Demographics
NPI:1871805309
Name:HOMSOMBATH, NILAPHONE NOK
Entity type:Individual
Prefix:
First Name:NILAPHONE
Middle Name:NOK
Last Name:HOMSOMBATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NILAPHONE
Other - Middle Name:NOK
Other - Last Name:KETTAVONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:380 FROG HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4904
Mailing Address - Country:US
Mailing Address - Phone:706-832-5046
Mailing Address - Fax:
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-774-8249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007194363A00000X
SC1787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant