Provider Demographics
NPI:1366656258
Name:THOMAS, GWENDOLYNN (AP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYNN
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-6104
Mailing Address - Country:US
Mailing Address - Phone:727-515-4741
Mailing Address - Fax:
Practice Address - Street 1:6701 38TH AVENUE NORTH
Practice Address - Street 2:SUITE #3
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710
Practice Address - Country:US
Practice Address - Phone:727-344-8690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP22072083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAP2207OtherDEPT OF HEALTH LICENSE