Healthcare Provider Details

I. General information

NPI: 1922059120
Provider Name (Legal Business Name): LAI THAO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11051 N SHERMAN RD
EDGERTON WI
53534-9002
US

IV. Provider business mailing address

11051 N SHERMAN RD
EDGERTON WI
53534-9002
US

V. Phone/Fax

Practice location:
  • Phone: 608-884-3354
  • Fax: 608-884-5024
Mailing address:
  • Phone: 608-884-3354
  • Fax: 608-884-5024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11615
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1923-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: