Healthcare Provider Details

I. General information

NPI: 1619576576
Provider Name (Legal Business Name): THETHONG P THEPVONG EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W BELGRAVIA AVE
FRESNO CA
93706-3909
US

IV. Provider business mailing address

1115 E GOSHEN AVE
FRESNO CA
93720-2621
US

V. Phone/Fax

Practice location:
  • Phone: 559-265-2045
  • Fax:
Mailing address:
  • Phone: 559-259-0994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberE119251
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: