Provider Demographics
NPI:1063428811
Name:VANG, PETER S (PA)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:S
Last Name:VANG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9300 E 29TH ST N
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-2182
Mailing Address - Country:US
Mailing Address - Phone:316-219-8299
Mailing Address - Fax:
Practice Address - Street 1:9300 E 29TH ST N
Practice Address - Street 2:SUITE 205
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2182
Practice Address - Country:US
Practice Address - Phone:316-219-8299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSAPPLIED FOR TEMP363AS0400X
KST-00858363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST-00858OtherSTATE LICENSE #