Basic Information
| Provider Information | |||||||||
| NPI: | 1790955300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TA | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TA | ||||||||
| OtherFirstName: | KHOI | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1288 | ||||||||
| Address2: | |||||||||
| City: | HOOPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955461288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306254261 | ||||||||
| FaxNumber: | 5306255171 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 AIRPORT ROAD | ||||||||
| Address2: | KIMAW MEDICAL CENTER, | ||||||||
| City: | HOOPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955461288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306254261 | ||||||||
| FaxNumber: | 5306255171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 04/04/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | A118947 | CA | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.