Provider Demographics
NPI:1003339920
Name:THOMAS, DERICK (PA-C)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 KENTUCKY AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3800
Mailing Address - Country:US
Mailing Address - Phone:270-228-3973
Mailing Address - Fax:270-359-5046
Practice Address - Street 1:2605 KENTUCKY AVE STE 102
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3800
Practice Address - Country:US
Practice Address - Phone:270-228-3973
Practice Address - Fax:270-359-5046
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant