Provider Demographics
NPI:1194900514
Name:PHAN, THAO H
Entity type:Individual
Prefix:MRS
First Name:THAO
Middle Name:H
Last Name:PHAN
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 1:1219 AMSTERDAM AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-7007
Mailing Address - Country:US
Mailing Address - Phone:212-749-8480
Mailing Address - Fax:212-316-6592
Practice Address - Street 1:1219 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-7007
Practice Address - Country:US
Practice Address - Phone:212-749-8480
Practice Address - Fax:212-316-6592
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02834206Medicaid
NY5922630001Medicare NSC