Healthcare Provider Details

I. General information

NPI: 1740295419
Provider Name (Legal Business Name): THAN AYE AW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 01/22/2026
Certification Date: 01/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5088 N FRESNO ST STE 104
FRESNO CA
93710-7611
US

IV. Provider business mailing address

143 W MAIN ST STE 104
MERCED CA
95340-4930
US

V. Phone/Fax

Practice location:
  • Phone: 559-222-9362
  • Fax: 559-222-9369
Mailing address:
  • Phone: 209-725-2060
  • Fax: 209-725-2072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberA53206
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberA53206
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberA53206
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberA53206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: