Provider Demographics
NPI:1336132026
Name:VAUGHN, THOMAS DEWAYNE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:DEWAYNE
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-0729
Mailing Address - Country:US
Mailing Address - Phone:334-793-2663
Mailing Address - Fax:
Practice Address - Street 1:1500 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-4754
Practice Address - Country:US
Practice Address - Phone:334-793-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL779363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-79539OtherBCBS OF ALABAMA -RCC
AL189447Medicaid
AL511-79540OtherBCBS OF ALABAMA - HWEST
AL188125Medicaid
AL102I977212OtherMEDICARE