Provider Demographics
NPI:1376961508
Name:VANG, WA
Entity Type:Individual
Prefix:
First Name:WA
Middle Name:
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 1:929 S SAN JOAQUIN ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-1415
Mailing Address - Country:US
Mailing Address - Phone:209-684-3683
Mailing Address - Fax:209-938-0281
Practice Address - Street 1:929 S SAN JOAQUIN ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-1415
Practice Address - Country:US
Practice Address - Phone:209-684-3683
Practice Address - Fax:209-938-0281
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)