Healthcare Provider Details

I. General information

NPI: 1336206945
Provider Name (Legal Business Name): ALLAN R THOMES CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 SIXTH AVENUE NORTH
ST CLOUD MN
56303
US

IV. Provider business mailing address

1200 SIXTH AVENUE NORTH
ST CLOUD MN
56303
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-5131
  • Fax: 320-240-2118
Mailing address:
  • Phone: 320-252-5131
  • Fax: 320-240-2118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR0921532
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: