Provider Demographics
NPI:1164072286
Name:VAN, THIEN-HUONG THERESA (PA)
Entity Type:Individual
Prefix:
First Name:THIEN-HUONG
Middle Name:THERESA
Last Name:VAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:VAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:3031 NE STEPHENS ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-6237
Mailing Address - Country:US
Mailing Address - Phone:541-229-7038
Mailing Address - Fax:541-464-4474
Practice Address - Street 1:3031 NE STEPHENS ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6237
Practice Address - Country:US
Practice Address - Phone:541-229-7038
Practice Address - Fax:541-464-4474
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA202904363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500791146Medicaid