Provider Demographics
NPI:1235213083
Name:DEITZ, THOMAS AARON (NP)
Entity Type:Individual
Prefix:PROF
First Name:THOMAS
Middle Name:AARON
Last Name:DEITZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 TOMAHAWK CIR
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-1600
Mailing Address - Country:US
Mailing Address - Phone:205-475-2002
Mailing Address - Fax:
Practice Address - Street 1:1725 PINE ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1109
Practice Address - Country:US
Practice Address - Phone:334-293-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX703720363L00000X
AL1-073507363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191852602Medicaid
TX191852601Medicaid
TX8K4412Medicare PIN
TX8L7762Medicare PIN