Provider Demographics
NPI:1508869785
Name:THOMAS, JERRY G JR (CRNA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:G
Last Name:THOMAS
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:G
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:3429 57TH AVENUE DR W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3518
Mailing Address - Country:US
Mailing Address - Phone:785-243-0454
Mailing Address - Fax:
Practice Address - Street 1:3429 57TH AVENUE DR W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3518
Practice Address - Country:US
Practice Address - Phone:785-243-0454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54616367500000X
FL9355144367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100331300GMedicaid
KS058433Medicare UPIN
KSP00000815Medicare ID - Type UnspecifiedRAILROAD MEDICARE
KS058433Medicare ID - Type UnspecifiedMEDICARE/BCBS