Healthcare Provider Details

I. General information

NPI: 1841908407
Provider Name (Legal Business Name): DR. KHOUA ALEX VANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 SILAS CREEK PKWY
WINSTON SALEM NC
27103-3013
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-718-7224
  • Fax: 336-718-7598
Mailing address:
  • Phone: 336-718-7224
  • Fax: 336-718-7598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberVANG-XFMC3
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5017254
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: