Provider Demographics
NPI:1790736932
Name:VONGCHANYAKUL, VANCHAI (PA)
Entity Type:Individual
Prefix:
First Name:VANCHAI
Middle Name:
Last Name:VONGCHANYAKUL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:530 N MONTE VISTA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4675
Mailing Address - Country:US
Mailing Address - Phone:580-436-7101
Mailing Address - Fax:580-436-4447
Practice Address - Street 1:3462 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:HEALDTON
Practice Address - State:OK
Practice Address - Zip Code:73438-6124
Practice Address - Country:US
Practice Address - Phone:580-229-0701
Practice Address - Fax:580-229-1454
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2014-11-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OKPA847363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKS62052Medicare UPIN