Provider Demographics
NPI:1053667444
Name:THOMAS, AMANDA B
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:B
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:CATHERINE
Other - Last Name:BACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-3205
Practice Address - Street 1:6250 OLD CANTON RD STE 130
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2946
Practice Address - Country:US
Practice Address - Phone:601-956-7280
Practice Address - Fax:601-977-6244
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2365225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02986263Medicaid
MS471411YJ5JMedicare PIN