Individual
SOURASACK KIT VONGSA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2500 E CAPITOL DR STE 1200, APPLETON, WI 54911
(920) 830-6877
(800) 236-2236
Mailing address
122 E COLLEGE AVE, APPLETON, WI 54911-5794
(920) 996-3264
(920) 830-5970
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
47253
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
34808400
—
WI
Enumeration date
03/08/2006
Last updated
08/19/2019
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