Provider Demographics
NPI:1720629843
Name:THAO, DIANA (PA-C)
Entity Type:Individual
Prefix:
First Name:DIANA
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 1:2090 HYACINTH AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-3253
Mailing Address - Country:US
Mailing Address - Phone:651-332-6826
Mailing Address - Fax:
Practice Address - Street 1:1054 SIMPSON ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-2404
Practice Address - Country:US
Practice Address - Phone:718-589-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant