Healthcare Provider Details

I. General information

NPI: 1871852731
Provider Name (Legal Business Name): CHRISTOPHER WEBB THOMAS M.S., ATC, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 04/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 GUSDORF RD STE A
TAOS NM
87571-6499
US

IV. Provider business mailing address

PO BOX 283
EL PRADO NM
87529-0283
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-0009
  • Fax: 575-758-8736
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number11-0619
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number539
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: