Individual
JUSTIN THAI THACH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
1217 119TH ST, COLLEGE POINT, NY 11356-1648
(646) 898-7446
Mailing address
1217 119TH ST, COLLEGE POINT, NY 11356-1648
(646) 898-7446
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
012085
NY
Other
Enumeration date
09/25/2007
Last updated
12/09/2015
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