Provider Demographics
NPI:1518384510
Name:LY, THU-THAO NGOC (DO)
Entity Type:Individual
Prefix:
First Name:THU-THAO
Middle Name:NGOC
Last Name:LY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-0005
Practice Address - Country:US
Practice Address - Phone:570-271-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS0204952085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program