Provider Demographics
NPI:1467741298
Name:LE, THAO NGOC (NP)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:NGOC
Last Name:LE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4302
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:877-469-8906
Practice Address - Street 1:14544 7TH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4214
Practice Address - Country:US
Practice Address - Phone:760-245-1025
Practice Address - Fax:877-469-8906
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20406363LF0000X
CANP20406363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFF:10/15/13-ADELANTMedicaid
CAP01288528/DU5182OtherRAILROAD MEDICARE-VICTORVILLE
CAEFF:10/21/13 VICTORVMedicaid
CAP01288528/DU5182OtherRAILROAD MEDICARE-VICTORVILLE