=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497322341
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH J THOMAS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2021
-----------------------------------------------------
Last Update Date | 06/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 836 PRUDENTIAL DR STE 1700
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-8344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-398-0125
-----------------------------------------------------
Fax | 904-398-1832
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 43667
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32203-3667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-720-0599
-----------------------------------------------------
Fax | 904-376-4036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9114363
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------