Provider Demographics
NPI:1508840828
Name:THOMAS, TRESARAE SHAWN (PAC)
Entity Type:Individual
Prefix:MS
First Name:TRESARAE
Middle Name:SHAWN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TRESARAE
Other - Middle Name:
Other - Last Name:PATE LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:2570 TURNPIKE RD
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35950-0501
Mailing Address - Country:US
Mailing Address - Phone:256-572-3271
Mailing Address - Fax:
Practice Address - Street 1:2505 US HIGHWAY 431
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957
Practice Address - Country:US
Practice Address - Phone:256-593-8310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009933282Medicaid
ALPA-430OtherALABAMA STATE LICENSE
ALQ54065Medicare UPIN
AL051556838PATMedicare PIN