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General NPI Number Information
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NPI Number | 1891007787
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Entity Type | Individual
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Provider Name | THOMAS C LY MD
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Gender | Male
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Dates
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Enumeration Date | 07/08/2010
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Last Update Date | 01/18/2012
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Provider Practice Location Address
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Address Line | 101 CIVIC CENTER LN
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5607
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Country | US
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Telephone | 928-854-0002
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Fax | 928-453-0885
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Provider Business Mailing Address
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Address Line | 13236 N 7TH ST STE 4- 255
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City | PHOENIX
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State | AZ
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Zip | 85022-5343
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Country | US
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Telephone | 928-854-0002
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Fax | 928-453-0885
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 45537
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License Number State | AZ
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