Provider Demographics
NPI:1912443086
Name:BACH, THUY
Entity Type:Individual
Prefix:
First Name:THUY
Middle Name:
Last Name:BACH
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 1:1601 MONTE VISTA AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-6604
Mailing Address - Country:US
Mailing Address - Phone:909-865-9501
Mailing Address - Fax:909-469-2146
Practice Address - Street 1:1601 MONTE VISTA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-6601
Practice Address - Country:US
Practice Address - Phone:909-630-7938
Practice Address - Fax:909-469-2118
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023479363A00000X
363A00000X
CAPA54204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912443086Medicaid
MB4237980OtherDEA