Provider Demographics
NPI:1396365326
Name:THOMAS, STEPHANIE MARTHA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARTHA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4917 DEER CREEK CIR S
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48094-4212
Mailing Address - Country:US
Mailing Address - Phone:586-337-2404
Mailing Address - Fax:
Practice Address - Street 1:1266 WALTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-6900
Practice Address - Country:US
Practice Address - Phone:810-230-0338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085008048363A00000X
MI5601010256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program