Provider Demographics
NPI:1558616680
Name:GITCHEL, THOMAS WALLACE JR (STNA, RN)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WALLACE
Last Name:GITCHEL
Suffix:JR
Gender:M
Credentials:STNA, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9470 HUNT RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43071-9758
Mailing Address - Country:US
Mailing Address - Phone:317-695-0153
Mailing Address - Fax:
Practice Address - Street 1:9470 HUNT RD
Practice Address - Street 2:
Practice Address - City:ST LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:43071-9758
Practice Address - Country:US
Practice Address - Phone:317-695-0153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-15
Last Update Date:2012-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH377484163W00000X
OH400929290609376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2991615Medicaid