Provider Demographics
NPI:1568634939
Name:THAO, PANG
Entity Type:Individual
Prefix:
First Name:PANG
Middle Name:
Last Name:THAO
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 1:155 ARCH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-4302
Mailing Address - Country:US
Mailing Address - Phone:651-665-0226
Mailing Address - Fax:651-204-0826
Practice Address - Street 1:379 UNIVERSITY AVE W STE 214
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2060
Practice Address - Country:US
Practice Address - Phone:651-665-0226
Practice Address - Fax:651-204-0826
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant