Provider Demographics
NPI:1598005050
Name:LO, THAO (PA-C)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:LO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-387-5511
Mailing Address - Fax:
Practice Address - Street 1:2727 PLAZA DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401
Practice Address - Country:US
Practice Address - Phone:715-847-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3076-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant