Healthcare Provider Details

I. General information

NPI: 1003888108
Provider Name (Legal Business Name): THOMAS D DEA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 12/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5633 N LIDGERWOOD ST
SPOKANE WA
99208-1224
US

IV. Provider business mailing address

910 N WASHINGTON ST SUITE 209
SPOKANE WA
99201-2202
US

V. Phone/Fax

Practice location:
  • Phone: 509-482-2460
  • Fax:
Mailing address:
  • Phone: 509-232-1173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003775
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: