Provider Demographics
NPI:1487427886
Name:XAYAVONGSONE, DISA (NP)
Entity type:Individual
Prefix:
First Name:DISA
Middle Name:
Last Name:XAYAVONGSONE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:NY
Mailing Address - Zip Code:14006-9630
Mailing Address - Country:US
Mailing Address - Phone:607-237-3727
Mailing Address - Fax:
Practice Address - Street 1:107 INSTITUTE ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6628
Practice Address - Country:US
Practice Address - Phone:716-484-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2024-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404954363LP0808X
NY743043163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse