Provider Demographics
NPI:1558020578
Name:VANG, MAI MOUA (NP)
Entity type:Individual
Prefix:
First Name:MAI MOUA
Middle Name:
Last Name:VANG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 AMERICAN BLVD W STE 300
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-4442
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:470 WATER ST
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-3089
Practice Address - Country:US
Practice Address - Phone:952-442-6950
Practice Address - Fax:952-955-6276
Is Sole Proprietor?:No
Enumeration Date:2021-12-17
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8987363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily