Provider Demographics
NPI:1578001004
Name:BROWN, THOMAS II
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BROWN
Suffix:II
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 1:2808 LA SALLE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-3775
Mailing Address - Country:US
Mailing Address - Phone:505-592-8893
Mailing Address - Fax:
Practice Address - Street 1:2808 LA SALLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-3775
Practice Address - Country:US
Practice Address - Phone:505-592-8893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM17-00010681372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider