| Doctor Name: | JUSTIN THAI THACH |
| NPI Number: | 1558558395 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA |
| License Number: | 012085 |
| Business Practice Address: | 1217 119th St College Point, NY - 113561648 |
| Business Phone Number: | 6468987446 |
| Business Fax Number: | |
| Mailing Address: | 1217 119th St, COLLEGE POINT |
| State: | NY |
| Postal Code: | 113561648 |
| Phone Number: | 6468987446 |
| Fax Number: | |
| NPI Enumeration Date: | 09/25/2007 |
| NPI Last Update Date: | 12/09/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AS0400X |
| License Number: | 012085 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Surgical |
| Taxonomy Definition: | |