Healthcare Provider Details

I. General information

NPI: 1922626969
Provider Name (Legal Business Name): TREVOR THOMAS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD
NEWARK DE
19718-2200
US

IV. Provider business mailing address

4755 OGLETOWN STANTON RD
NEWARK DE
19718-2200
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-3475
  • Fax: 302-325-7056
Mailing address:
  • Phone: 302-733-3475
  • Fax: 302-325-7056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC5-0011420
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: