Provider Demographics
NPI:1639802135
Name:MOUA, KENG
Entity Type:Individual
Prefix:
First Name:KENG
Middle Name:
Last Name:MOUA
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 1:1614 FORDEM AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-4646
Mailing Address - Country:US
Mailing Address - Phone:414-303-2469
Mailing Address - Fax:
Practice Address - Street 1:1614 FORDEM AVE APT 106
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4646
Practice Address - Country:US
Practice Address - Phone:414-303-2469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-03
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant