Basic Information
| Provider Information | |||||||||
| NPI: | 1447357694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANCHUIN | ||||||||
| FirstName: | THONGDANG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 999 EXECUTIVE PARK BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243250 | ||||||||
| FaxNumber: | 4232243258 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 VIRGINIA AVE NE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | NORTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242731538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766790818 | ||||||||
| FaxNumber: | 2766790817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0101029458 | VA | Y | Allopathic & Osteopathic Physicians | Surgery | 208D00000X | 0101029458 | VA | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 010041660 | 05 | VA | MEDICAID |