Provider Demographics
NPI:1225361702
Name:THOMASON, DALLAS MICHELLE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:DALLAS
Middle Name:MICHELLE
Last Name:THOMASON
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 1:1907 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3711
Mailing Address - Country:US
Mailing Address - Phone:601-636-1173
Mailing Address - Fax:601-638-8287
Practice Address - Street 1:1907 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-636-1173
Practice Address - Fax:601-638-8287
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant