Healthcare Provider Details

I. General information

NPI: 1356394514
Provider Name (Legal Business Name): JOHN C THOMAS P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E 19TH ST
ROSWELL NM
88201-5151
US

IV. Provider business mailing address

115 E 19TH ST
ROSWELL NM
88201-5151
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-7600
  • Fax: 575-622-3856
Mailing address:
  • Phone: 575-622-7600
  • Fax: 575-622-3856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number96-PA07
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number96-PA07
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: