Provider Demographics
NPI:1093275240
Name:LEE-VANG, PANG HOUA (NP)
Entity Type:Individual
Prefix:
First Name:PANG
Middle Name:HOUA
Last Name:LEE-VANG
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 1:4108 81ST AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-2545
Mailing Address - Country:US
Mailing Address - Phone:612-281-8727
Mailing Address - Fax:
Practice Address - Street 1:4108 81ST AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-2545
Practice Address - Country:US
Practice Address - Phone:612-281-8727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6476363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner