Provider Demographics
NPI:1316100118
Name:SYSAVATH, KHOM
Entity type:Individual
Prefix:
First Name:KHOM
Middle Name:
Last Name:SYSAVATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 JOHNSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187
Mailing Address - Country:US
Mailing Address - Phone:507-372-5517
Mailing Address - Fax:
Practice Address - Street 1:23 EMPIRE DRIVE
Practice Address - Street 2:SUITE 123
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103
Practice Address - Country:US
Practice Address - Phone:651-222-2787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant