Healthcare Provider Details

I. General information

NPI: 1306180146
Provider Name (Legal Business Name): YE THU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2012
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1162 MONTGOMERY DR FL 3
SANTA ROSA CA
95405-4802
US

IV. Provider business mailing address

1162 MONTGOMERY DR FL 3
SANTA ROSA CA
95405-4802
US

V. Phone/Fax

Practice location:
  • Phone: 707-890-4250
  • Fax:
Mailing address:
  • Phone: 707-890-4250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberA134154
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: