MEDICARE: TASHA THOMAS CST

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	246ZC0007X	Surgical Assistant

General Provider Information

NPI Number	:	1912144494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TASHA THOMAS CST

Provider Business Mailing Address
First Line	:	1604 VISA DR STE 1
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-2195
Country	:	US
Telephone Number	:	309-846-4716
Fax Number	:

Provider Business Practice Location Address
First Line	:	1604 VISA DR STE 1
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-2195
Country	:	US
Telephone Number	:	309-846-4716
Fax Number	:

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

Provider Enumeration Date	:	01/20/2009
Last Update Date	:	01/20/2009

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Directions to “ TASHA THOMAS CST” Practice Location

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