Healthcare Provider Details

I. General information

NPI: 1114752292
Provider Name (Legal Business Name): IA VANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

577 S PEACH AVE
FRESNO CA
93727-3952
US

IV. Provider business mailing address

159 N SHELLY AVE
FRESNO CA
93727-3651
US

V. Phone/Fax

Practice location:
  • Phone: 559-251-8463
  • Fax:
Mailing address:
  • Phone: 720-471-3090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number53324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: