Healthcare Provider Details

I. General information

NPI: 1790736932
Provider Name (Legal Business Name): VANCHAI VONGCHANYAKUL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3462 HOSPITAL RD
HEALDTON OK
73438-6124
US

IV. Provider business mailing address

530 N MONTE VISTA ST SUITE A
ADA OK
74820-4675
US

V. Phone/Fax

Practice location:
  • Phone: 580-229-0701
  • Fax: 580-229-1454
Mailing address:
  • Phone: 580-436-7101
  • Fax: 580-436-4447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA847
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: