Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | LA |
NPI | 1003012287 |
---|---|
Provider Name | Brenda Thomason |
First Address | Monroe, LA 71201-2111 |
Second Address | Monroe, LA 71203-2372 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1442399 | TDK AMC GROUP AID PROVIDE (01) | LA |
1664821 | (05) | LA |