Provider Demographics
NPI:1245243807
Name:THOMAS, NATHAN B (DPM)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:B
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 SOUTH AVE WEST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801
Mailing Address - Country:US
Mailing Address - Phone:406-542-2108
Mailing Address - Fax:406-542-2195
Practice Address - Street 1:110 SOUTH AVE WEST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-542-2108
Practice Address - Fax:406-542-2195
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT146213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0390320Medicaid
MT0390320Medicaid
U61976Medicare UPIN
MT010001848Medicare ID - Type Unspecified