Provider Demographics
NPI:1124723788
Name:LAI, PHU DUC (CCP)
Entity type:Individual
Prefix:
First Name:PHU
Middle Name:DUC
Last Name:LAI
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 BLOOMING LEAF WAY
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-5130
Mailing Address - Country:US
Mailing Address - Phone:815-319-2779
Mailing Address - Fax:
Practice Address - Street 1:6411 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-704-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI154-18242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist