Provider Demographics
NPI:1124213566
Name:THOMAS, MATTHEW A
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-1109
Mailing Address - Country:US
Mailing Address - Phone:651-307-0754
Mailing Address - Fax:320-589-1808
Practice Address - Street 1:618 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-1943
Practice Address - Country:US
Practice Address - Phone:320-589-3652
Practice Address - Fax:320-589-1808
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17201662593747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant