Provider Demographics
NPI:1619962842
Name:WOODS, THOMAS R (PA C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:WOODS
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1846
Mailing Address - Country:US
Mailing Address - Phone:920-730-4435
Mailing Address - Fax:
Practice Address - Street 1:1501 S MADISON ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1846
Practice Address - Country:US
Practice Address - Phone:920-730-4435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI84023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42913100Medicaid
WI42913100Medicaid
WI0289 45300Medicare PIN