Provider Demographics
NPI:1033495163
Name:THOMAS, KENNETH FRED JR (DPT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:FRED
Last Name:THOMAS
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2123
Practice Address - Street 1:1072 MARKET ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-2458
Practice Address - Country:US
Practice Address - Phone:570-217-2144
Practice Address - Fax:570-415-0124
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADAPT002916225100000X
PAPT021720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA768441OtherMEDICARE
PA1026544360029Medicaid