Provider Demographics
NPI:1922059120
Name:THAO, LAI (PA-C)
Entity Type:Individual
Prefix:
First Name:LAI
Middle Name:
Last Name:THAO
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 1:11051 N SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-9002
Mailing Address - Country:US
Mailing Address - Phone:608-884-3354
Mailing Address - Fax:608-884-5024
Practice Address - Street 1:11051 N SHERMAN RD
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-9002
Practice Address - Country:US
Practice Address - Phone:608-884-3354
Practice Address - Fax:608-884-5024
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11615363A00000X
WI1923-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1922059120Medicaid