Provider Demographics
NPI:1437754801
Name:WOLONG, SIDDHARTHA M G HANNIBAL (LAC)
Entity Type:Individual
Prefix:
First Name:SIDDHARTHA
Middle Name:M G HANNIBAL
Last Name:WOLONG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:JOSEPH
Other - Last Name:FRANCO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HANNIBAL WOLONG LAC
Mailing Address - Street 1:329 E HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55355-2295
Mailing Address - Country:US
Mailing Address - Phone:320-699-6061
Mailing Address - Fax:
Practice Address - Street 1:329 E HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355-2295
Practice Address - Country:US
Practice Address - Phone:320-699-0161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1695171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP146113245311OtherDRIVERS LICENSE
MN1695OtherSTATE OF MN MINNESOTA BOARDS OF MEDICAL PRACTICE