MEDICARE: MRS. DICKEY WANGMO THUKHOTSONG

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	163W00000X	Registered Nurse	95080619	CA
2	363LF0000X	Family Nurse Practitioner	95015915	CA

General Provider Information

NPI Number	:	1467055855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DICKEY WANGMO THUKHOTSONG

Provider Business Mailing Address
First Line	:	2410 HIGH SCHOOL AVE
Second Line	:
City	:	CONCORD
State	:	CA
Zip	:	94520-1829
Country	:	US
Telephone Number	:	510-734-3560
Fax Number	:

Provider Business Practice Location Address
First Line	:	3230 CARLSON BLVD
Second Line	:
City	:	EL CERRITO
State	:	CA
Zip	:	94530-3907
Country	:	US
Telephone Number	:	510-734-3560
Fax Number	:

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

Provider Enumeration Date	:	11/18/2020
Last Update Date	:	11/18/2020

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