Provider Demographics
NPI:1992373013
Name:RAJVONG, WILLIE P
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:P
Last Name:RAJVONG
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 1:350 RUCKER LN APT 555
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-3241
Mailing Address - Country:US
Mailing Address - Phone:615-809-6525
Mailing Address - Fax:
Practice Address - Street 1:1332 SOUTHERN DR
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30460-1360
Practice Address - Country:US
Practice Address - Phone:912-478-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist