Provider Demographics
NPI:1790295715
Name:LITHYOUVONG, INDRE (PA-C)
Entity type:Individual
Prefix:
First Name:INDRE
Middle Name:
Last Name:LITHYOUVONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:INDRE
Other - Middle Name:
Other - Last Name:STASIUNAITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2321 ATHERHOLT RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2113
Mailing Address - Country:US
Mailing Address - Phone:434-485-7382
Mailing Address - Fax:434-947-3992
Practice Address - Street 1:2321 ATHERHOLT RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2113
Practice Address - Country:US
Practice Address - Phone:434-947-3993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005957363A00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology