Provider Demographics
NPI:1487023248
Name:THOMAS, CLAYTON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CLAYTON
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-0030
Mailing Address - Country:US
Mailing Address - Phone:423-784-5771
Mailing Address - Fax:423-455-0380
Practice Address - Street 1:402 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1238
Practice Address - Country:US
Practice Address - Phone:606-549-2656
Practice Address - Fax:606-549-2855
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA3108363A00000X
KYPA2058363A00000X
KYTC413363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100405120Medicaid
TNQ026771Medicaid
KY2058OtherSTATE LICENSE
TN3108OtherSTATE LICENSE