Provider Demographics
NPI:1003568452
Name:NGO, JONATHON THAI (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:THAI
Last Name:NGO
Suffix:
Gender:M
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 1:2293 HAWES AVE APT 1427
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-4646
Mailing Address - Country:US
Mailing Address - Phone:832-541-4359
Mailing Address - Fax:
Practice Address - Street 1:255 LEBANON ROAD
Practice Address - Street 2:UNIT 132
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75036
Practice Address - Country:US
Practice Address - Phone:469-310-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty