Provider Demographics
NPI:1528600012
Name:PEMBERTON, THOMAS J
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:PEMBERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11518 E APACHE TRL STE 129
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-3572
Mailing Address - Country:US
Mailing Address - Phone:480-317-2214
Mailing Address - Fax:
Practice Address - Street 1:618 S MADISON DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-7248
Practice Address - Country:US
Practice Address - Phone:480-784-1514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN196326163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health