Provider Demographics
NPI:1093267700
Name:THOMAS, ANJU (PA-C)
Entity Type:Individual
Prefix:
First Name:ANJU
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
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 1:675 N SAINT CLAIR ST STE 18-250
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5980
Mailing Address - Country:US
Mailing Address - Phone:312-695-8624
Mailing Address - Fax:312-695-4741
Practice Address - Street 1:675 N SAINT CLAIR ST STE 18-250
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5980
Practice Address - Country:US
Practice Address - Phone:312-695-8624
Practice Address - Fax:312-695-4741
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058759363A00000X
NJ25MP00414600363AS0400X
IL085008232363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical