MEDICARE: VAN NGO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R 0075671	OK

General Provider Information

NPI Number	:	1316343908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VAN NGO

Provider Business Mailing Address
First Line	:	4413 SOUTH LEE AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4413 SOUTH LEE AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109
Country	:	US
Telephone Number	:	405-631-0611
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2014
Last Update Date	:	11/10/2014

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Directions to “ VAN NGO ” Practice Location

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