Provider Demographics
NPI:1588220222
Name:INTHAVONGSA, JOHN S (DNP RN AGACNP-BC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:INTHAVONGSA
Suffix:
Gender:M
Credentials:DNP RN AGACNP-BC
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Mailing Address - Street 1:454 W ALEXANDRINE ST APT 18
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1787
Mailing Address - Country:US
Mailing Address - Phone:347-963-1896
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-3000
Practice Address - Fax:313-745-4707
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2021-06-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4704309696163W00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse