Healthcare Provider Details

I. General information

NPI: 1740697937
Provider Name (Legal Business Name): MARK DAVID THOMAS RN, MS, PNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2014
Last Update Date: 07/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1534 CLAY ST APT 5
SAN FRANCISCO CA
94109-3848
US

IV. Provider business mailing address

1534 CLAY ST APT 5
SAN FRANCISCO CA
94109-3848
US

V. Phone/Fax

Practice location:
  • Phone: 918-557-0039
  • Fax:
Mailing address:
  • Phone: 918-557-0039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95000964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: