Healthcare Provider Details

I. General information

NPI: 1487023248
Provider Name (Legal Business Name): CLAYTON THOMAS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 CUMBERLAND AVE
WILLIAMSBURG KY
40769-1238
US

IV. Provider business mailing address

PO BOX 30
JELLICO TN
37762-0030
US

V. Phone/Fax

Practice location:
  • Phone: 606-549-2656
  • Fax: 606-549-2855
Mailing address:
  • Phone: 423-784-5771
  • Fax: 423-455-0380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3108
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2058
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: