Healthcare Provider Details

I. General information

NPI: 1639726227
Provider Name (Legal Business Name): LARRY THOMAS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

594 CLEVELAND ST
MACON GA
31206-1561
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-1000
  • Fax:
Mailing address:
  • Phone: 478-719-9995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number9500
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: