Healthcare Provider Details

I. General information

NPI: 1497820211
Provider Name (Legal Business Name): THOMAS G DE TORRES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W JACKSON ST STE 206
CARBONDALE IL
62901-1474
US

IV. Provider business mailing address

1900 E MAIN ST
DANVILLE IL
61832-5100
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-3006
  • Fax: 618-457-3007
Mailing address:
  • Phone: 217-554-5467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085000963
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: