Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 099007166 | OR |
N | 363LW0102X | Nurse Practitioner - Women's Health | 099007166N1 | OR |
NPI | 1093715930 |
---|---|
Provider Name | Mrs. Carol Thomas |
First Address | Grants Pass, OR 97526-1556 |
Second Address | Grants Pass, OR 97526-1269 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2005 |
Last Update Date | 18/05/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
212874 | (05) | OR |
S46604 | (02) | OR |