Provider Demographics
NPI:1114699428
Name:THA, LILI
Entity Type:Individual
Prefix:
First Name:LILI
Middle Name:
Last Name:THA
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 1:300 BALLENGER CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-7096
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:
Practice Address - Street 1:300 BALLENGER CENTER DR
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-7096
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDC0008722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program