Provider Demographics
NPI:1730423807
Name:REUNGWETWATTANA, THANYANAN (MD)
Entity type:Individual
Prefix:
First Name:THANYANAN
Middle Name:
Last Name:REUNGWETWATTANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275B EVANS ST
Mailing Address - Street 2:APT # 6
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5666
Mailing Address - Country:US
Mailing Address - Phone:507-319-1774
Mailing Address - Fax:
Practice Address - Street 1:ROSWELL PARK CANCER INSTITUTE
Practice Address - Street 2:ELM & CARLTON STREETS
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263-0001
Practice Address - Country:US
Practice Address - Phone:716-845-4101
Practice Address - Fax:716-845-3423
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP86261174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist