Provider Demographics
NPI:1063456879
Name:WANSLEBEN, THOMAS OSBORN (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:OSBORN
Last Name:WANSLEBEN
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 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-653-9500
Mailing Address - Fax:603-650-0915
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-653-9500
Practice Address - Fax:603-650-0915
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH40005138Medicaid
VT0AP0936Medicaid
NHAP093602Medicare PIN
NH40005138Medicaid
VT0AP0936Medicaid