Provider Demographics
NPI:1982018560
Name:PHAN, THAO
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 GOSFORD RD
Mailing Address - Street 2:APT 224
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93313-6100
Mailing Address - Country:US
Mailing Address - Phone:714-889-0076
Mailing Address - Fax:
Practice Address - Street 1:1809 CECIL AVE
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-1519
Practice Address - Country:US
Practice Address - Phone:661-725-1312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70249183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist