Healthcare Provider Details

I. General information

NPI: 1144223355
Provider Name (Legal Business Name): HANNAH-NGOC T HA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12401 OLIVE BLVD STE 202
CREVE COEUR MO
63141-5448
US

IV. Provider business mailing address

12401 OLIVE BLVD STE 202
CREVE COEUR MO
63141-5448
US

V. Phone/Fax

Practice location:
  • Phone: 314-834-2888
  • Fax: 314-834-5212
Mailing address:
  • Phone: 314-834-2888
  • Fax: 314-834-5212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2001028190
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number2001028190
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: