MEDICARE: HAILEY GRACE THOM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	15539	MN

General Provider Information

NPI Number	:	1487400347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAILEY GRACE THOM

Provider Business Mailing Address
First Line	:	2925 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1321
Country	:	US
Telephone Number	:	612-262-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 E 28TH ST STE 401
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-3723
Country	:	US
Telephone Number	:	612-863-0200
Fax Number	:	612-863-0235

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2024
Last Update Date	:	01/13/2026

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Directions to “ HAILEY GRACE THOM ” Practice Location

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