Healthcare Provider Details

I. General information

NPI: 1487644985
Provider Name (Legal Business Name): MUAJ C LO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MOUA VANG

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 CESAR CHAVEZ ST
WEST ST. PAUL MN
55107-2226
US

IV. Provider business mailing address

153 CESAR CHAVEZ ST
WEST ST. PAUL MN
55107-2226
US

V. Phone/Fax

Practice location:
  • Phone: 651-222-1816
  • Fax: 651-222-1305
Mailing address:
  • Phone: 651-222-1816
  • Fax: 651-222-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47517
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number54717
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: