Provider Demographics
NPI:1023319746
Name:PHOU, THAI SENG (PA-C)
Entity type:Individual
Prefix:MR
First Name:THAI
Middle Name:SENG
Last Name:PHOU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:THAI
Other - Middle Name:SENG
Other - Last Name:PHOU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:4338 SUFFOLK ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-7812
Mailing Address - Country:US
Mailing Address - Phone:909-226-1100
Mailing Address - Fax:
Practice Address - Street 1:11190 WARNER AVE STE 306
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4045
Practice Address - Country:US
Practice Address - Phone:714-432-9990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21328363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant