Healthcare Provider Details

I. General information

NPI: 1487634135
Provider Name (Legal Business Name): MARNEERAT P. VONGXAIBURANA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 9 VETERANS AFFAIRS MEDICAL CENTER
MARTINSBURG WV
25401-9809
US

IV. Provider business mailing address

201 E 5TH AVE
RANSON WV
25438-1613
US

V. Phone/Fax

Practice location:
  • Phone: 304-263-0811
  • Fax:
Mailing address:
  • Phone: 304-728-8800
  • Fax: 304-728-4794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number10320
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: