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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 ID||1275770398|
|PAC ID by PECOS||7012073596|
|Professional Enrollment ID||I20090309000141|
|Medical School Name||OTHER|
|Primary Specialty||NURSE PRACTITIONER|
|All secondary specialties|
|Group Practice PAC ID||1153498225|
|Number of Group Practice members||0|
|Address||300 HEBRON AVE, , GLASTONBURY, CT, 60332176|
|Hospital affiliation LBN|