Provider Demographics
NPI:1114329448
Name:VANG, GOUA LEO
Entity Type:Individual
Prefix:
First Name:GOUA
Middle Name:LEO
Last Name:VANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11140 GIBSON RD
Mailing Address - Street 2:
Mailing Address - City:WALDRON
Mailing Address - State:AR
Mailing Address - Zip Code:72958-8293
Mailing Address - Country:US
Mailing Address - Phone:479-357-9260
Mailing Address - Fax:
Practice Address - Street 1:11140 GIBSON RD
Practice Address - Street 2:
Practice Address - City:WALDRON
Practice Address - State:AR
Practice Address - Zip Code:72958-8293
Practice Address - Country:US
Practice Address - Phone:479-357-9260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver