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General NPI Number Information
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NPI Number | 1619945524
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Entity Type | Individual
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Provider Name | SOURASACK KIT VONGSA MD
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Gender | Male
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Dates
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Enumeration Date | 03/08/2006
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Last Update Date | 08/19/2019
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Provider Practice Location Address
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Address Line | 2500 E CAPITOL DR STE 1200
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City | APPLETON
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State | WI
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Zip | 54911
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Country | US
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Telephone | 920-830-6877
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Fax | 800-236-2236
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Provider Business Mailing Address
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Address Line | 122 E COLLEGE AVE
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City | APPLETON
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State | WI
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Zip | 54911-5794
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Country | US
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Telephone | 920-996-3264
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Fax | 920-830-5970
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 47253
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License Number State | WI
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