Healthcare Provider Details

I. General information

NPI: 1508869785
Provider Name (Legal Business Name): JERRY G THOMAS JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAY G THOMAS CRNA

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3429 57TH AVENUE DR W
BRADENTON FL
34210-3518
US

IV. Provider business mailing address

3429 57TH AVENUE DR W
BRADENTON FL
34210-3518
US

V. Phone/Fax

Practice location:
  • Phone: 785-243-0454
  • Fax:
Mailing address:
  • Phone: 785-243-0454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number54616
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9355144
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: