Provider Demographics
NPI:1497468714
Name:THOMAS, PORSCHE' QUINCOLA (MEDICAL WIG PROVIDER)
Entity Type:Individual
Prefix:
First Name:PORSCHE'
Middle Name:QUINCOLA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MEDICAL WIG PROVIDER
Other - Prefix:
Other - First Name:POR'SHAY
Other - Middle Name:QUINCOLA
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:POR'SHAY THOMAS
Mailing Address - Street 1:3535 PEACHTREE RD NE
Mailing Address - Street 2:P.O.BOX 527
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326
Mailing Address - Country:US
Mailing Address - Phone:734-686-7523
Mailing Address - Fax:
Practice Address - Street 1:3535 PEACHTREE RD NE STE 527
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-3287
Practice Address - Country:US
Practice Address - Phone:734-686-7523
Practice Address - Fax:404-671-8588
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA146N00000X, 335E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies