Provider Demographics
NPI:1164092805
Name:MYERS, THOMAS FRANK (RN)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:FRANK
Last Name:MYERS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6901 GALENA RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-3193
Mailing Address - Country:US
Mailing Address - Phone:309-689-2180
Mailing Address - Fax:
Practice Address - Street 1:6901 N GALENA RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3193
Practice Address - Country:US
Practice Address - Phone:309-689-2180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041339152163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL123456789Medicaid