Provider Demographics
NPI:1467659276
Name:THOMAS, MEAGAN L (PA)
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:L
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEAGAN
Other - Middle Name:L
Other - Last Name:KRUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 271429
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-1429
Mailing Address - Country:US
Mailing Address - Phone:602-385-2115
Mailing Address - Fax:
Practice Address - Street 1:2940 E BANNER GATEWAY DR STE 200
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2171
Practice Address - Country:US
Practice Address - Phone:602-772-3800
Practice Address - Fax:602-772-3801
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6211363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI025622245Medicare PIN