Healthcare Provider Details

I. General information

NPI: 1861146318
Provider Name (Legal Business Name): DEJAVAUGHN THOMAS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3714 PARVISS ST
PITTSBURGH PA
15212-1944
US

IV. Provider business mailing address

3714 PARVISS ST
PITTSBURGH PA
15212-1944
US

V. Phone/Fax

Practice location:
  • Phone: 412-636-7441
  • Fax:
Mailing address:
  • Phone: 412-636-7441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN710172
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: