Provider Demographics
NPI:1629670914
Name:MAI, THERESA (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MAI
Suffix:
Gender:F
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 1:2690 S WHITE RD STE 50
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2075
Mailing Address - Country:US
Mailing Address - Phone:408-223-7000
Mailing Address - Fax:408-223-7001
Practice Address - Street 1:1086 WOODMINSTER DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-2776
Practice Address - Country:US
Practice Address - Phone:408-390-2645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2023-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant