Provider Demographics
NPI:1619576576
Name:THEPVONG, THETHONG P (EMT)
Entity Type:Individual
Prefix:
First Name:THETHONG
Middle Name:P
Last Name:THEPVONG
Suffix:
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 E GOSHEN AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2621
Mailing Address - Country:US
Mailing Address - Phone:559-259-0994
Mailing Address - Fax:
Practice Address - Street 1:900 W BELGRAVIA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-3909
Practice Address - Country:US
Practice Address - Phone:559-265-2045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE119251207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services