| Doctor Name: | LAO PHA |
| NPI Number: | 1245639301 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 374889 |
| Business Practice Address: | 171 Lake St N # 102 Big Lake, MN - 553099254 |
| Business Phone Number: | 6517741166 |
| Business Fax Number: | |
| Mailing Address: | 171 Lake St N # 102, BIG LAKE |
| State: | MN |
| Postal Code: | 553099254 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 08/14/2014 |
| NPI Last Update Date: | 08/14/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 172A00000X |
| License Number: | 374889 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Driver |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A person employed to operate a motor vehicle as a carrier of persons or property. |