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General NPI Number Information
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NPI Number | 1629304654
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Entity Type | Individual
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Provider Name | THIRATH MARK LUONG PA-C
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Gender | Male
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Dates
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Enumeration Date | 10/27/2009
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Last Update Date | 10/31/2025
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Provider Practice Location Address
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Address Line | 17210 KENYON AVE
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City | LAKEVILLE
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State | MN
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Zip | 55044-6903
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Country | US
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Telephone | 651-968-5201
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Fax | 651-968-5903
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Provider Business Mailing Address
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Address Line | 710 COMMERCE DR STE 200
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City | WOODBURY
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State | MN
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Zip | 55125-4925
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Country | US
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Telephone | 651-968-5200
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 10898
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License Number State | MN
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