Provider Demographics
NPI:1740295419
Name:AW, THAN AYE (MD)
Entity type:Individual
Prefix:DR
First Name:THAN
Middle Name:AYE
Last Name:AW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4844 N 1ST ST
Mailing Address - Street 2:SUITE # 104
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-0529
Mailing Address - Country:US
Mailing Address - Phone:559-221-9088
Mailing Address - Fax:559-221-9087
Practice Address - Street 1:4844 N 1ST ST
Practice Address - Street 2:SUITE # 104
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-0529
Practice Address - Country:US
Practice Address - Phone:559-221-9088
Practice Address - Fax:559-221-9087
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA53206207RG0300X, 261Q00000X, 314000000X
171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770473417OtherTAX ID
CA00A532060Medicaid
CA00A532060Medicare PIN
CAF90620Medicare UPIN
CA00A532060Medicaid