Provider Demographics
NPI:1215684584
Name:YANG, KEVIN KONGMENG
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:KONGMENG
Last Name:YANG
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 1:3705 WINDING RIDGE WAY APT 39
Mailing Address - Street 2:
Mailing Address - City:SCHOFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54476-6801
Mailing Address - Country:US
Mailing Address - Phone:715-212-3071
Mailing Address - Fax:
Practice Address - Street 1:1010 N 8TH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1278
Practice Address - Country:US
Practice Address - Phone:715-748-9020
Practice Address - Fax:715-748-9022
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21244-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist