Healthcare Provider Details

I. General information

NPI: 1871936948
Provider Name (Legal Business Name): GINA R THOMSON CPM, LM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10345 ALTA VISTA RD
FORT WORTH TX
76244-6501
US

IV. Provider business mailing address

10345 ALTA VISTA RD
FORT WORTH TX
76244-6501
US

V. Phone/Fax

Practice location:
  • Phone: 817-562-2828
  • Fax:
Mailing address:
  • Phone: 817-562-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number99174
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: