Provider Demographics
NPI:1124686514
Name:NGO, MONGTU THI (PA-C)
Entity type:Individual
Prefix:MISS
First Name:MONGTU
Middle Name:THI
Last Name:NGO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 N FRANKLIN ST APT A2
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-2345
Mailing Address - Country:US
Mailing Address - Phone:248-633-3177
Mailing Address - Fax:
Practice Address - Street 1:22 N FRANKLIN ST APT A2
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2345
Practice Address - Country:US
Practice Address - Phone:248-633-3177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4928-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical