MEDICARE: ANGELINA VIVI THAI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1376428854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELINA VIVI THAI

Provider Business Mailing Address
First Line	:	2904 TRANQUILITY RD
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-9399
Country	:	US
Telephone Number	:	602-721-2367
Fax Number	:

Provider Business Practice Location Address
First Line	:	2904 TRANQUILITY RD
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-9399
Country	:	US
Telephone Number	:	602-721-2367
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2025
Last Update Date	:	08/06/2025

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