Healthcare Provider Details

I. General information

NPI: 1083119291
Provider Name (Legal Business Name): NICOLAS TYLER THOMASON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 W ZIA RD
SANTA FE NM
87505-6996
US

IV. Provider business mailing address

4630 RAIL RUNNER RD
SANTA FE NM
87507-0807
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-3450
  • Fax:
Mailing address:
  • Phone: 806-441-9399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License NumberDO2022-0126
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: