MEDICARE: MR. BRIAN THOMAS PMHNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP8948	AZ

General Provider Information

NPI Number	:	1588111264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN THOMAS PMHNP

Provider Business Mailing Address
First Line	:	202 E EARLL DR
Second Line	:	#200
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2634
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2715 N 3RD ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-1106
Country	:	US
Telephone Number	:	602-808-2800
Fax Number	:	602-808-2799

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

Provider Enumeration Date	:	09/09/2016
Last Update Date	:	09/12/2016

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