Provider Demographics
NPI:1619346376
Name:BLACK, THOMAS (NP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 QUAIL TRAIL
Mailing Address - Street 2:UNIT B
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015
Mailing Address - Country:US
Mailing Address - Phone:505-208-0204
Mailing Address - Fax:505-717-2884
Practice Address - Street 1:104 QUAIL TRAIL
Practice Address - Street 2:UNIT B
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015
Practice Address - Country:US
Practice Address - Phone:505-208-0208
Practice Address - Fax:505-717-2884
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM02922363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily