Basic Information
| Provider Information | |||||||||
| NPI: | 1326624834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THANTACHEVA | ||||||||
| FirstName: | THANAPATH | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | THANTACHEVA | ||||||||
| OtherFirstName: | DAVID | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7335 ARROWROCK AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891791252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029854381 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3100 N TENAYA WAY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029625000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2021 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.