Provider Demographics
NPI:1396171336
Name:LOUPRASONG, LATHANIKONE LANGSTON (PA)
Entity type:Individual
Prefix:
First Name:LATHANIKONE
Middle Name:LANGSTON
Last Name:LOUPRASONG
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 1:3737 SOUTHERN BLVD STE 2100
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1285
Mailing Address - Country:US
Mailing Address - Phone:937-433-5309
Mailing Address - Fax:937-298-0287
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-6010
Practice Address - Fax:937-395-8162
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50003874146D00000X
OH50.003874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant