Provider Demographics
NPI:1619945524
Name:VONGSA, SOURASACK KIT (MD)
Entity Type:Individual
Prefix:
First Name:SOURASACK
Middle Name:KIT
Last Name:VONGSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5794
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5970
Practice Address - Street 1:2500 E CAPITOL DR STE 1200
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911
Practice Address - Country:US
Practice Address - Phone:920-830-6877
Practice Address - Fax:800-236-2236
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34808400Medicaid
WII47689Medicare UPIN
WI453000612Medicare PIN
WI71480-0211Medicare ID - Type UnspecifiedMEDICARE
WI34808400Medicaid