Healthcare Provider Details

I. General information

NPI: 1598953143
Provider Name (Legal Business Name): THOMAS JOSEPH PLAZA MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 W 15TH ST
HAZLETON PA
18201-2616
US

IV. Provider business mailing address

1109 W 15TH ST
HAZLETON PA
18201-2616
US

V. Phone/Fax

Practice location:
  • Phone: 570-453-0252
  • Fax: 570-453-0253
Mailing address:
  • Phone: 570-453-0252
  • Fax: 570-453-0253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT016317
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier077630
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDICARE PROVIDER NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: