Provider Demographics
NPI:1093340846
Name:DOUGHERTY, THEA (PA-C)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:
Last Name:DOUGHERTY
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 1:652 ROUTE 12
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-2716
Mailing Address - Country:US
Mailing Address - Phone:908-947-5634
Mailing Address - Fax:
Practice Address - Street 1:652 ROUTE 12
Practice Address - Street 2:
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-2716
Practice Address - Country:US
Practice Address - Phone:908-947-5634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant