Healthcare Provider Details

I. General information

NPI: 1760254890
Provider Name (Legal Business Name): MATHEW VONGTHARANGSY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 M ST
FRESNO CA
93721-1808
US

IV. Provider business mailing address

5204 E GRANT AVE
FRESNO CA
93727-3204
US

V. Phone/Fax

Practice location:
  • Phone: 559-264-2700
  • Fax:
Mailing address:
  • Phone: 559-367-8006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number728201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: