Provider Demographics
NPI:1558558395
Name:THACH, JUSTIN THAI (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:THAI
Last Name:THACH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 119TH ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11356-1648
Mailing Address - Country:US
Mailing Address - Phone:646-898-7446
Mailing Address - Fax:
Practice Address - Street 1:1217 119TH ST
Practice Address - Street 2:
Practice Address - City:COLLEGE POINT
Practice Address - State:NY
Practice Address - Zip Code:11356-1648
Practice Address - Country:US
Practice Address - Phone:646-898-7446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012085363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical