Healthcare Provider Details

I. General information

NPI: 1013368885
Provider Name (Legal Business Name): SWE THAN M.D.,PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 COFFEE RD
MODESTO CA
95355-4201
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 209-550-4702
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA158060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: