Basic Information
| Provider Information | |||||||||
| NPI: | 1922059120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THAO | ||||||||
| FirstName: | LAI | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11051 N SHERMAN RD | ||||||||
| Address2: | |||||||||
| City: | EDGERTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535349002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088843354 | ||||||||
| FaxNumber: | 6088845024 | ||||||||
| Practice Location | |||||||||
| Address1: | 11051 N SHERMAN RD | ||||||||
| Address2: | |||||||||
| City: | EDGERTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535349002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088843354 | ||||||||
| FaxNumber: | 6088845024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 11615 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1923-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1922059120 | 05 | WI | MEDICAID |