Provider Demographics
NPI:1750377693
Name:WANGSUWANA, MIRACLE (DO)
Entity type:Individual
Prefix:DR
First Name:MIRACLE
Middle Name:
Last Name:WANGSUWANA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 NORTH PECOS ROAD
Mailing Address - Street 2:2ND FLOOR WEST SIDE 2B 152 VA SOUTHERN NEVADA
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89086
Mailing Address - Country:US
Mailing Address - Phone:702-791-9161
Mailing Address - Fax:702-895-4014
Practice Address - Street 1:6900 NORTH PECOS ROAD
Practice Address - Street 2:2ND FLOOR WEST SIDE 2B152 VA SOUTHERN NEVADA
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086
Practice Address - Country:US
Practice Address - Phone:702-791-9161
Practice Address - Fax:702-671-5891
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12532084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500484Medicaid
NV100500484Medicaid