Provider Demographics
NPI:1174586671
Name:LOUANGXAY, PHATHSADY (PA)
Entity type:Individual
Prefix:MR
First Name:PHATHSADY
Middle Name:
Last Name:LOUANGXAY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16149
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-0697
Mailing Address - Country:US
Mailing Address - Phone:401-453-9625
Mailing Address - Fax:401-435-7069
Practice Address - Street 1:164 SUMMIT AVE # C70
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-4545
Practice Address - Fax:401-793-7866
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00356363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1396864542OtherNPI KENT HOSPITAL PBO
RI9004070Medicaid
RI9004070Medicaid