Healthcare Provider Details

I. General information

NPI: 1508801671
Provider Name (Legal Business Name): THOMAS L. PROSSER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6110 STATE ROAD 70 E
BRADENTON FL
34203-9707
US

IV. Provider business mailing address

3501 CORTEZ RD W
BRADENTON FL
34210-3104
US

V. Phone/Fax

Practice location:
  • Phone: 941-755-4242
  • Fax: 941-755-1906
Mailing address:
  • Phone: 941-752-2700
  • Fax: 941-752-2730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2121
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: