Provider Demographics
NPI:1508099367
Name:THOMAS, LEE WALTER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:WALTER
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:130 DESIARD ST
Mailing Address - Street 2:SUITE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:2516 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2988
Practice Address - Country:US
Practice Address - Phone:318-807-4956
Practice Address - Fax:318-998-4462
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2019-06-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAPA.200473363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2158295Medicaid
LA2158295Medicaid
LA5C989PF01Medicare PIN