Healthcare Provider Details

I. General information

NPI: 1073217238
Provider Name (Legal Business Name): KA THAO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 COWELL BLVD
DAVIS CA
95618-6325
US

IV. Provider business mailing address

1955 COWELL BLVD
DAVIS CA
95618-6325
US

V. Phone/Fax

Practice location:
  • Phone: 530-757-7100
  • Fax:
Mailing address:
  • Phone: 530-757-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA203955
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: