Provider Demographics
NPI:1760446603
Name:VANADURONGVAN, KANYA (MD)
Entity Type:Individual
Prefix:
First Name:KANYA
Middle Name:
Last Name:VANADURONGVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13516 SODAK RD
Mailing Address - Street 2:
Mailing Address - City:WILMOT
Mailing Address - State:SD
Mailing Address - Zip Code:57279-8211
Mailing Address - Country:US
Mailing Address - Phone:605-938-4574
Mailing Address - Fax:
Practice Address - Street 1:803 E MILBANK AVE
Practice Address - Street 2:
Practice Address - City:MILBANK
Practice Address - State:SD
Practice Address - Zip Code:57252-1413
Practice Address - Country:US
Practice Address - Phone:605-432-4587
Practice Address - Fax:605-432-4580
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2408208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN299363500Medicaid
SD6700334Medicaid
AV8069949OtherDEA #
MN299363500Medicaid
SDS6165Medicare PIN