Provider Demographics
NPI:1467529735
Name:DEROCHE, THOMAS WILLIAM (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:WILLIAM
Last Name:DEROCHE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7870W US HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-8992
Mailing Address - Country:US
Mailing Address - Phone:906-341-3200
Mailing Address - Fax:
Practice Address - Street 1:7870W US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-8992
Practice Address - Country:US
Practice Address - Phone:906-341-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002637363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical