Basic Information
| Provider Information | |||||||||
| NPI: | 1790736932 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VONGCHANYAKUL | ||||||||
| FirstName: | VANCHAI | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 N MONTE VISTA ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804367101 | ||||||||
| FaxNumber: | 5804364447 | ||||||||
| Practice Location | |||||||||
| Address1: | 3462 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | HEALDTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734386124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802290701 | ||||||||
| FaxNumber: | 5802291454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 11/20/2014 | ||||||||
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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 | 363AM0700X | PA847 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.