Healthcare Provider Details

I. General information

NPI: 1669398053
Provider Name (Legal Business Name): THOMAS GLEN RADER FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 MAPLE LEAF DR
AUSTINTOWN OH
44515-2228
US

IV. Provider business mailing address

176 MAPLE LEAF DR
AUSTINTOWN OH
44515-2228
US

V. Phone/Fax

Practice location:
  • Phone: 330-787-6574
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06260928
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: