Provider Demographics
NPI:1639944390
Name:XIONG, SUPANAWONG
Entity Type:Individual
Prefix:
First Name:SUPANAWONG
Middle Name:
Last Name:XIONG
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 1:1515 GOLF RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7457
Mailing Address - Country:US
Mailing Address - Phone:651-274-6118
Mailing Address - Fax:
Practice Address - Street 1:1515 GOLF RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-7457
Practice Address - Country:US
Practice Address - Phone:651-274-6118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIX5207800017205343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)