Healthcare Provider Details

I. General information

NPI: 1558916247
Provider Name (Legal Business Name): SHINY SUSAN THOMAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7615,EAST BASELINE ROAD
MESA AZ
85209
US

IV. Provider business mailing address

99 S GOLD DR
APACHE JUNCTION AZ
85120-5035
US

V. Phone/Fax

Practice location:
  • Phone: 480-962-0101
  • Fax:
Mailing address:
  • Phone: 480-962-0101
  • Fax: 480-962-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberRNP230519
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: