MEDICARE: ANDREA NICOLE THOMAS PAC

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	2001016022	MO
2	363A00000X	Physician Assistant	085001633	IL

General Provider Information

NPI Number	:	1538152657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA NICOLE THOMAS PAC

Provider Business Mailing Address
First Line	:	PO BOX 955534
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63195-5534
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 ELEVEN SOUTH 2E
Second Line	:
City	:	COLUMBIA
State	:	IL
Zip	:	62236
Country	:	US
Telephone Number	:	618-206-6120
Fax Number	:

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

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	02/10/2025

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Directions to “ ANDREA NICOLE THOMAS PAC” Practice Location

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