Provider Demographics
NPI:1497120760
Name:MITCHAM, THADDEUS DWAYNE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:THADDEUS
Middle Name:DWAYNE
Last Name:MITCHAM
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:354 MEDICAL GROUP
Mailing Address - Street 2:2630 CENTRAL AVE
Mailing Address - City:EIELSON AFB
Mailing Address - State:AK
Mailing Address - Zip Code:99702-2301
Mailing Address - Country:US
Mailing Address - Phone:907-377-6127
Mailing Address - Fax:
Practice Address - Street 1:354 MEDICAL GROUP
Practice Address - Street 2:2630 CENTRAL AVE
Practice Address - City:EIELSON AFB
Practice Address - State:AK
Practice Address - Zip Code:99702-2301
Practice Address - Country:US
Practice Address - Phone:907-377-6127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2023-08-18
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant