Provider Demographics
NPI:1689609364
Name:NGUYEN, THAO TP (DO)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:TP
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:FRIENDSHIP
Mailing Address - State:WI
Mailing Address - Zip Code:53934-9699
Mailing Address - Country:US
Mailing Address - Phone:608-339-3331
Mailing Address - Fax:
Practice Address - Street 1:402 W LAKE ST
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:53934-9699
Practice Address - Country:US
Practice Address - Phone:608-339-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25094207Q00000X
WI62437207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00458926OtherRR MEDICARE
OR275291Medicaid
G97286Medicare UPIN
OR275291Medicaid
ORR119137Medicare PIN
ORR130126Medicare PIN
ORR148321Medicare PIN
ORR144557Medicare PIN
ORR120631Medicare PIN