Provider Demographics
NPI:1619434537
Name:VANG, SUPHAMAS
Entity Type:Individual
Prefix:
First Name:SUPHAMAS
Middle Name:
Last Name:VANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1039 ROBERT ST S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-1455
Mailing Address - Country:US
Mailing Address - Phone:651-207-6510
Mailing Address - Fax:651-493-7908
Practice Address - Street 1:1039 ROBERT ST S
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-1455
Practice Address - Country:US
Practice Address - Phone:651-207-6510
Practice Address - Fax:651-493-7908
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider