MEDICARE: MR. WAYSHAWN DERMON THOMAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	T62925822	VA

General Provider Information

NPI Number	:	1053885723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WAYSHAWN DERMON THOMAS

Provider Business Mailing Address
First Line	:	212 CARLSTONE DR
Second Line	:
City	:	HIGHLAND SPRINGS
State	:	VA
Zip	:	23075-2503
Country	:	US
Telephone Number	:	804-586-9436
Fax Number	:

Provider Business Practice Location Address
First Line	:	212 CARLSTONE DR
Second Line	:
City	:	HIGHLAND SPRINGS
State	:	VA
Zip	:	23075-2503
Country	:	US
Telephone Number	:	804-586-9436
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2019
Last Update Date	:	01/16/2019

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