Provider Demographics
NPI:1164733697
Name:HUMPHREY, THOMAS RANDALL (PA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RANDALL
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:1357 HEMBREE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5722
Practice Address - Country:US
Practice Address - Phone:770-475-7550
Practice Address - Fax:770-343-9080
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2015-01-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA001599363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ21706Medicare UPIN