Basic Information
| Provider Information | |||||||||
| NPI: | 1972173524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANADURONGVAN | ||||||||
| FirstName: | TYLER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 4TH ST APT 504 | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511011702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122393938 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2501 PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511043725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122945000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2021 | ||||||||
| LastUpdateDate: | 06/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R-12297 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.