Provider Demographics
NPI:1174848683
Name:THAMMAVONGSA, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:THAMMAVONGSA
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:PSC 482
Mailing Address - Street 2:BOX 155
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362-9998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3D MED BN, 3D MLG
Practice Address - Street 2:H&S CO UNIT #38447
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96604-8447
Practice Address - Country:US
Practice Address - Phone:315-623-4960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman