Provider Demographics
NPI:1659958296
Name:VANG, PACHA (COTA)
Entity Type:Individual
Prefix:
First Name:PACHA
Middle Name:
Last Name:VANG
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1034
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53008-1034
Mailing Address - Country:US
Mailing Address - Phone:262-264-8789
Mailing Address - Fax:
Practice Address - Street 1:13900 W BURLEIGH RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-3019
Practice Address - Country:US
Practice Address - Phone:262-781-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI8618005Other8618005
WI8618005Other8618005