Provider Demographics
NPI:1003041534
Name:CHURCH, THOMAS GARY (FNP)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:GARY
Last Name:CHURCH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 STATE FARM RD.
Mailing Address - Street 2:STE. 2
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5391
Mailing Address - Country:US
Mailing Address - Phone:828-386-1001
Mailing Address - Fax:828-358-1317
Practice Address - Street 1:838 STATE FARM RD.
Practice Address - Street 2:STE. 2
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5391
Practice Address - Country:US
Practice Address - Phone:828-386-1001
Practice Address - Fax:828-358-1317
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC184774363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner