Provider Demographics
NPI:1154022010
Name:VANG, JERRY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:VANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4879 E ATCHISON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93725-1201
Mailing Address - Country:US
Mailing Address - Phone:559-570-4948
Mailing Address - Fax:
Practice Address - Street 1:4879 E ATCHISON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93725-1201
Practice Address - Country:US
Practice Address - Phone:559-570-4948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB049162343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)