MEDICARE: MANIVAN THOR VANG RN

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
1	163WH0200X	Home Health Registered Nurse	116073-30	WI
2	163WA2000X	Administrator Registered Nurse	116073-30	WI

General Provider Information

NPI Number	:	1992224588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANIVAN THOR VANG RN

Provider Business Mailing Address
First Line	:	2110 N SHERMAN AVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53704-3933
Country	:	US
Telephone Number	:	608-217-3642
Fax Number	:	608-856-0440

Provider Business Practice Location Address
First Line	:	2110 N SHERMAN AVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53704-3933
Country	:	US
Telephone Number	:	608-217-3642
Fax Number	:	608-856-0440

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2017
Last Update Date	:	03/08/2026

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