Provider Demographics
NPI:1417474180
Name:HART, THOMAS WAYNE (NP-BC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:WAYNE
Last Name:HART
Suffix:
Gender:M
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-6431
Mailing Address - Country:US
Mailing Address - Phone:229-560-0252
Mailing Address - Fax:858-216-1971
Practice Address - Street 1:705 OKALOOSA ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32310-5455
Practice Address - Country:US
Practice Address - Phone:229-560-0252
Practice Address - Fax:858-216-1971
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN214796363L00000X, 363LA2200X, 363LG0600X, 363LP2300X
FLAPRN9346173363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003212736AMedicaid