MEDICARE: MARK DAVID THOMAS RN, MS, PNP

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	363LP0200X	Pediatric Nurse Practitioner	95000964	CA

General Provider Information

NPI Number	:	1740697937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK DAVID THOMAS RN, MS, PNP

Provider Business Mailing Address
First Line	:	1534 CLAY ST APT 5
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-3848
Country	:	US
Telephone Number	:	918-557-0039
Fax Number	:

Provider Business Practice Location Address
First Line	:	1534 CLAY ST APT 5
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-3848
Country	:	US
Telephone Number	:	918-557-0039
Fax Number	:

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

Provider Enumeration Date	:	07/19/2014
Last Update Date	:	07/19/2014

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