Basic Information
| Provider Information | |||||||||
| NPI: | 1750875332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TU | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | DO, MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 367 S GULPH RD | ||||||||
| Address2: | |||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194063121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758511505 | ||||||||
| FaxNumber: | 7758511583 | ||||||||
| Practice Location | |||||||||
| Address1: | 5575 KIETZKE LN | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895112290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758511505 | ||||||||
| FaxNumber: | 7758511583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2018 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | DO2970 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | V69885 | 01 | NV | PTAN | OTHER | 250015250 | 05 | NV | MEDICAID |