Provider Demographics
NPI:1124770433
Name:THAO, TINA MAI HOUA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MAI HOUA
Last Name:THAO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 W RUSSET CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-6285
Mailing Address - Country:US
Mailing Address - Phone:715-572-0765
Mailing Address - Fax:
Practice Address - Street 1:2300 W RUSSET CT
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-6285
Practice Address - Country:US
Practice Address - Phone:715-572-0765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver