Healthcare Provider Details

I. General information

NPI: 1558425868
Provider Name (Legal Business Name): MARK ALLEN THOMAS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

220 BRIDGEVIEW CIR
CHESAPEAKE VA
23322-4014
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-3420
  • Fax:
Mailing address:
  • Phone: 843-263-4188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number4704220074
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704220074
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: