Provider Demographics
NPI:1750447249
Name:VONGPRASERT, CHANDA DALIDA
Entity Type:Individual
Prefix:
First Name:CHANDA
Middle Name:DALIDA
Last Name:VONGPRASERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHENDA
Other - Middle Name:PRASERT
Other - Last Name:VONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15978 HYLAND POINTE CT
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7063
Mailing Address - Country:US
Mailing Address - Phone:952-432-5145
Mailing Address - Fax:
Practice Address - Street 1:15978 HYLAND POINTE CT
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7063
Practice Address - Country:US
Practice Address - Phone:952-432-5145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist