Provider Demographics
NPI:1558322693
Name:THOMAS, TUDUR GWYN (PT, MBA)
Entity Type:Individual
Prefix:MR
First Name:TUDUR
Middle Name:GWYN
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3113
Mailing Address - Country:US
Mailing Address - Phone:575-652-3515
Mailing Address - Fax:575-652-3518
Practice Address - Street 1:2205 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3113
Practice Address - Country:US
Practice Address - Phone:575-652-3515
Practice Address - Fax:575-652-3518
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000S8096Medicaid
NM561922ZQ4JMedicare PIN