Provider Demographics
NPI:1437505500
Name:RUNSCAVAGE, THOMAS III
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:RUNSCAVAGE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:LUZERNE
Mailing Address - State:PA
Mailing Address - Zip Code:18709-1034
Mailing Address - Country:US
Mailing Address - Phone:570-855-9459
Mailing Address - Fax:
Practice Address - Street 1:816 NORTH ST
Practice Address - Street 2:
Practice Address - City:LUZERNE
Practice Address - State:PA
Practice Address - Zip Code:18709-1034
Practice Address - Country:US
Practice Address - Phone:570-855-9459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP016085363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology