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NPI Code Detail

MEDICARE: DR. MIRACLE WANGSUWANA D.O.

MEDICARE: DR. MIRACLE WANGSUWANA D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12084N0400XNeurology Physician1253NV

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1750377693
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MIRACLE WANGSUWANA D.O.
Provider Business Mailing Address
First Line : 6900 NORTH PECOS ROAD
Second Line : 2ND FLOOR WEST SIDE 2B 152 VA SOUTHERN NEVADA
City : NORTH LAS VEGAS
State : NV
Zip : 89086
Country : US
Telephone Number : 702-791-9161
Fax Number : 702-895-4014
Provider Business Practice Location Address
First Line : 6900 NORTH PECOS ROAD
Second Line : 2ND FLOOR WEST SIDE 2B152 VA SOUTHERN NEVADA
City : NORTH LAS VEGAS
State : NV
Zip : 89086
Country : US
Telephone Number : 702-791-9161
Fax Number : 702-671-5891
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/26/2005
Last Update Date : 05/28/2024

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