Provider Demographics
NPI:1467327577
Name:LE, THAO VAN
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:VAN
Last Name:LE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 COYOTE TRL
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:SD
Mailing Address - Zip Code:57719-9454
Mailing Address - Country:US
Mailing Address - Phone:501-813-0806
Mailing Address - Fax:
Practice Address - Street 1:640 FLORMANN ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4679
Practice Address - Country:US
Practice Address - Phone:605-755-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-08
Last Update Date:2025-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP003855363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily