MEDICARE: ADDISON THAO

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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1578319760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADDISON THAO

Provider Business Mailing Address
First Line	:	18212 79TH PL N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-1911
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18212 79TH PL N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-1911
Country	:	US
Telephone Number	:	763-291-0903
Fax Number	:

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

Provider Enumeration Date	:	04/29/2024
Last Update Date	:	04/29/2024

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Directions to “ ADDISON THAO ” Practice Location

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