Basic Information
| Provider Information | |||||||||
| NPI: | 1245420710 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THAO | ||||||||
| FirstName: | MAI | ||||||||
| MiddleName: | SEE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8508 EMERY PKWY N | ||||||||
| Address2: | |||||||||
| City: | CHAMPLIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553162494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634427872 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13819 HANSON BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553047608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633924001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2007 | ||||||||
| LastUpdateDate: | 03/27/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 107717 | 01 | MN | NCCPA ID | OTHER |