Provider Demographics
NPI:1194466813
Name:WOODCOCK, THAI THAO (CSFA)
Entity Type:Individual
Prefix:MRS
First Name:THAI
Middle Name:THAO
Last Name:WOODCOCK
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15085 RANIER AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4650
Mailing Address - Country:US
Mailing Address - Phone:228-313-2286
Mailing Address - Fax:
Practice Address - Street 1:15085 RANIER AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4650
Practice Address - Country:US
Practice Address - Phone:228-313-2286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS208458246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant