Healthcare Provider Details

I. General information

NPI: 1861891657
Provider Name (Legal Business Name): DWAYNE THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 ELM ST NE
ALBUQUERQUE NM
87102-3672
US

IV. Provider business mailing address

4604 SAM BRATTON AVE NW
ALBUQUERQUE NM
87114-5333
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-5550
  • Fax:
Mailing address:
  • Phone: 909-800-5035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number3089
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number27045
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: