MINDY BACCAM SOUTHAMMAVONG (NPI# 1528434859) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1528434859 |
| Entity Type | Individual |
| Full Name | MINDY BACCAM SOUTHAMMAVONG |
| Other Name | MINDY SHINE BACCAM |
| Credential | PA-C |
| Practice Address |
405 Monroe St Pella IA 50219-1189 |
| Practice Telephone | 6416212200 |
| Practice Fax Number | 6416212335 |
| Mailing Telephone | 6416212200 |
| Mailing Fax Number | 6416212335 |
| Enumeration Date | 2015-08-20 |
| Last Update Date | 2017-05-01 |
| Gender Code | F |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 363AM0700X |
Physician Assistant Specialization: Medical |
078982 | IA | Physician Assistants & Advanced Practice Nursing Providers |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| IA | NPI NUMBER | 1528434859 | 01 |
| IA | IOWA LICENSE | 078982 | 01 |
| Street Address |
405 MONROE ST |
| City | PELLA |
| State | IA |
| Zip Code | 50219-1189 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1477557411 | Dale Lee Lensing | Obstetrics & Gynecology | 405 Monroe St, Pella, IA 50219-1189 | 2005-06-08 |
| 1932619475 | Pella Regional Health Center Clinic Pharmacy | Pharmacy | 405 Monroe St, Pella, IA 50219 | 2017-10-11 |
| 1952810087 | Jessica Lee Streeter | Nurse Practitioner | 405 Monroe St, Pella, IA 50219-1189 | 2017-09-20 |
| 1740649300 | Tamara Jean Pommer | Physical Therapist | 405 Monroe St, Pella, IA 50219-1189 | 2016-02-11 |
| 1750740361 | Janna Marie Hansen-nolin | Speech-Language Pathologist | 405 Monroe St, Pella, IA 50219-1189 | 2016-02-11 |
| 1487013017 | Tara Dawn Temperly-leidigh | Speech-Language Pathologist | 405 Monroe St, Pella, IA 50219-1189 | 2016-02-10 |
| 1275991804 | Jacklyn Sue Lowe | Speech-Language Pathologist | 405 Monroe St, Pella, IA 50219-1189 | 2016-02-10 |
| 1487012001 | Amy Jean Herdegen | Physical Therapist | 405 Monroe St, Pella, IA 50219-1189 | 2016-02-10 |
| 1225496854 | Sarah Christine Vogel | Occupational Therapist | 405 Monroe St, Pella, IA 50219-1189 | 2016-02-10 |
| 1275922908 | Jana Renee Rus | Nurse Practitioner | 405 Monroe St, Pella, IA 50219-1189 | 2015-01-19 |
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| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1366967101 | Emily Rachel Dine | Specialist/Technologist | 812 University, Pella, IA 50219 | 2017-08-12 |
| 1588105597 | Brett Boddicker | Student in an Organized Health Care Education/Training Program | 812 University Street, Pella, IA 50219 | 2017-03-10 |
| 1053780098 | Jeremy Richard Dolder | Specialist/Technologist | 812 University St., Pella, IA 50219 | 2015-09-21 |
| 1588921084 | Michael Gary Walsh | Psychiatry & Neurology | 710 W 1st St, Pella, IA 50219 | 2012-04-20 |
| 1063788602 | Multicultural International Counseling Enterprises, Inc. | Psychologist | 311 Franklin Street, Pella, IA 50219 | 2012-03-28 |
| 1568798056 | Megan Lee Nelson | Physical Therapist | 405 Monroe Street, Pella, IA 50219 | 2009-10-19 |
| 1578783247 | Suzanne Vonseggern | Pharmacist | 1610 Vemeer Rd, East Plant 3, Pella, IA 50219 | 2007-04-26 |
| 1669513057 | Heather Renee Pilcher | Physical Therapy Assistant | 308 Se 9th St., Pella, IA 50219 | 2007-02-09 |
| 1164578134 | Walgreen Co. | Pharmacy | 1610 Vermeer Road East, Plant 3 1/2, Pella, IA 50219 | 2007-01-25 |
| 1841373289 | Jeffrey Frank Allen | Dentist | 839 Broadway, Pella, IA 50219 | 2006-10-21 |
| Find all providers in zip 50219 | ||||
| Taxonomy Code | 363AM0700X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Physician Assistant |
| Specialization | Medical |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1962885707 | Jordan Lea Greiner | Physician Assistant | 2605 Washington St, Iowa Dermatology Inc, Pella, IA 50219-7924 | 2015-06-29 |
| 1588928428 | Heather Marie Opseth | Physician Assistant | 405 Monroe St, Pella, IA 50219-1189 | 2012-06-26 |
| 1558339267 | Jennifer L Wadle | Physician Assistant | 405 Monroe St, Pella, IA 50219-1189 | 2006-03-09 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1306468434 | Nichole Marie Steffens | Physician Assistant | 2371 County Road B32, Fort Atkinson, IA 52144-7414 | 2020-05-12 |
| 1558869321 | Devan Louis Depauw | Physician Assistant | 1227 East Rusholme St., Davenport, IA 52803 | 2018-01-26 |
| 1295282325 | Courtney Lowy | Physician Assistant | 3850 Merle Hay Rd Ste 500, Des Moines, IA 50310-1322 | 2016-09-07 |
| 1447641618 | West Broadway Clinic, P.C. | Physician Assistant | 1701 W Broadway, Council Bluffs, IA 51501-3822 | 2015-02-10 |
| 1972858397 | Sarah Beth Nace | Physician Assistant | 2346 Mormon Trek Blvd Ste 1500, Iowa City, IA 52246-4368 | 2012-07-23 |
| 1528313350 | Stephanie Elaine Fangman | Physician Assistant | 709 W Main St Ste 3, Manchester, IA 52057-1526 | 2012-07-18 |
| 1679707947 | Integrative Medicine Consultants, Inc. | Physician Assistant | 507 Main Avenue, Clear Lake, IA 50428 | 2009-05-14 |
| 1992960876 | Cass County Memorial Hospital Rhc | Physician Assistant | 1501 E 10th St Ste 100, Atlantic, IA 50022-1936 | 2008-07-21 |
| 1629265368 | Hannah Joy Lokenvitz | Physician Assistant | 700 2nd St Se Ste 101, Hampton, IA 50441-2655 | 2007-09-26 |
| 1568658532 | Angela K Grundmeyer | Physician Assistant | 1215 Pleasant St Ste 100, Des Moines, IA 50309-1409 | 2007-09-24 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.