Basic Information
| Provider Information | |||||||||
| NPI: | 1467741298 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | THAO | ||||||||
| MiddleName: | NGOC | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 8774698906 | ||||||||
| Practice Location | |||||||||
| Address1: | 14544 7TH ST | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923954214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602451025 | ||||||||
| FaxNumber: | 8774698906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2011 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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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 | 363LF0000X | 20406 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | NP20406 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | EFF:10/15/13-ADELANT | 05 | CA | MEDICAID | P01288528/DU5182 | 01 | CA | RAILROAD MEDICARE-VICTORVILLE | OTHER | EFF:10/21/13 VICTORV | 05 | CA | MEDICAID |