Provider Demographics
NPI:1932843687
Name:VANG, MENGMORE
Entity Type:Individual
Prefix:
First Name:MENGMORE
Middle Name:
Last Name:VANG
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 1:2396 N FOWLER AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1703
Mailing Address - Country:US
Mailing Address - Phone:559-284-5047
Mailing Address - Fax:
Practice Address - Street 1:1396 W HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-7126
Practice Address - Country:US
Practice Address - Phone:559-256-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker