Provider Demographics
NPI:1467055855
Name:THUKHOTSONG, DICKEY WANGMO
Entity Type:Individual
Prefix:MRS
First Name:DICKEY
Middle Name:WANGMO
Last Name:THUKHOTSONG
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 1:2410 HIGH SCHOOL AVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1829
Mailing Address - Country:US
Mailing Address - Phone:510-734-3560
Mailing Address - Fax:
Practice Address - Street 1:3230 CARLSON BLVD
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-3907
Practice Address - Country:US
Practice Address - Phone:510-734-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95080619163W00000X
CA95015915363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse