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SUSADA INTHAVONG
OTHER

SUSADA INTHAVONG is physician registered in the Centers for Medicare & Medicaid Services (CMS). The National Provider Identifier (NPI) of the National Plan and Provider Enumeration System (NPPES) is 1275770398. The unique individual professional ID assigned by Provider Enrollment, Chain, and Ownership System (PECOS) is 7012073596. The primary specialty is NURSE PRACTITIONER. The organization is . The address is 300 HEBRON AVE, , GLASTONBURY, CT, 60332176. The zip code is 60332176.


Nation Provider ID1275770398
PAC ID by PECOS7012073596
Professional Enrollment IDI20090309000141
NameSUSADA INTHAVONG
Medical School NameOTHER
Graduation Year2008
Primary SpecialtyNURSE PRACTITIONER
All secondary specialties
Organization Name
Group Practice PAC ID1153498225
Number of Group Practice members0
Address300 HEBRON AVE, , GLASTONBURY, CT, 60332176
Hospital affiliation LBN
Graduation Year2008
Contact Number8606599990
Email Address[Show_Email_ID]
Phone Number[Show_Phone]
Website [Show_Website]