Healthcare Provider Details

I. General information

NPI: 1275772964
Provider Name (Legal Business Name): THEK MOUANOUTOUA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4929 E KINGS CANYON RD
FRESNO CA
93727-3812
US

IV. Provider business mailing address

4929 E. KINGS CANYON ROAD
FRESNO CA
93727-3812
US

V. Phone/Fax

Practice location:
  • Phone: 559-255-6476
  • Fax:
Mailing address:
  • Phone: 559-255-6476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number20176
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: