Provider Demographics
NPI:1043685605
Name:VANG, TONG LOU (DPT, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:TONG
Middle Name:LOU
Last Name:VANG
Suffix:
Gender:M
Credentials:DPT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 HAZELWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2048
Mailing Address - Country:US
Mailing Address - Phone:651-325-8324
Mailing Address - Fax:
Practice Address - Street 1:550 ROSELAWN AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-2120
Practice Address - Country:US
Practice Address - Phone:651-774-9765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9987225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist