Healthcare Provider Details

I. General information

NPI: 1790758118
Provider Name (Legal Business Name): ANDREW J THOMAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 PHALEN BLVD MAIL STOP 51103H
SAINT PAUL MN
55130-5302
US

IV. Provider business mailing address

435 PHALEN BLVD MAIL STOP 51103H
SAINT PAUL MN
55130-5302
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-8300
  • Fax: 651-254-8379
Mailing address:
  • Phone: 651-254-8300
  • Fax: 651-254-8379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number22266
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: