Healthcare Provider Details

I. General information

NPI: 1881044089
Provider Name (Legal Business Name): NATHAN MICHAEL THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2016
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 HICKMAN RD
DES MOINES IA
50314-1505
US

IV. Provider business mailing address

1288 VALLEY VIEW DR
COUNCIL BLUFFS IA
51503-5245
US

V. Phone/Fax

Practice location:
  • Phone: 515-282-5640
  • Fax: 515-282-2332
Mailing address:
  • Phone: 712-328-8800
  • Fax: 712-328-8461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR-10665
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD46785
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: