Basic Information
| Provider Information | |||||||||
| NPI: | 1871181065 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUACH | ||||||||
| FirstName: | TOMMY | ||||||||
| MiddleName: | HA | ||||||||
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| Credential: | CAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11011 W NORTH AVE APT 469 | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532262275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8322282979 | ||||||||
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| Practice Location | |||||||||
| Address1: | W180N8085 TOWN HALL RD | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530513518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622511000 | ||||||||
| FaxNumber: | 2625185052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2021 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 179-17 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.