Healthcare Provider Details

I. General information

NPI: 1750377693
Provider Name (Legal Business Name): MIRACLE WANGSUWANA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 05/28/2024
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 NORTH PECOS ROAD 2ND FLOOR WEST SIDE 2B152 VA SOUTHERN NEVADA
NORTH LAS VEGAS NV
89086
US

IV. Provider business mailing address

6900 NORTH PECOS ROAD 2ND FLOOR WEST SIDE 2B 152 VA SOUTHERN NEVADA
NORTH LAS VEGAS NV
89086
US

V. Phone/Fax

Practice location:
  • Phone: 702-791-9161
  • Fax: 702-671-5891
Mailing address:
  • Phone: 702-791-9161
  • Fax: 702-895-4014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number1253
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: