Provider Demographics
NPI:1528434859
Name:SOUTHAMMAVONG, MINDY BACCAM (PA-C)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:BACCAM
Last Name:SOUTHAMMAVONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:SHINE
Other - Last Name:BACCAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:405 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1189
Mailing Address - Country:US
Mailing Address - Phone:641-621-2200
Mailing Address - Fax:641-621-2335
Practice Address - Street 1:405 MONROE ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1189
Practice Address - Country:US
Practice Address - Phone:641-621-2200
Practice Address - Fax:641-621-2335
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA078982363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1528434859OtherNPI NUMBER
IA078982OtherIOWA LICENSE
IA560910077Medicare PIN