Provider Demographics
NPI:1982133807
Name:THAO, PA KOU VANG (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:PA KOU
Middle Name:VANG
Last Name:THAO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:HORTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54944-9355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:508 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-4337
Practice Address - Country:US
Practice Address - Phone:920-731-6304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7641-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily