Provider Demographics
NPI:1407968712
Name:LY, THUC N (PA-C)
Entity Type:Individual
Prefix:
First Name:THUC
Middle Name:N
Last Name:LY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:LY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:3433 FIONNA PL
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-5703
Mailing Address - Country:US
Mailing Address - Phone:626-675-8169
Mailing Address - Fax:
Practice Address - Street 1:3433 FIONNA PL
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-5703
Practice Address - Country:US
Practice Address - Phone:626-675-8169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16370363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA952662606OtherGRP TAX ID #
CABS398YMedicare PIN
CA952662606OtherGRP TAX ID #