Provider Demographics
NPI:1629036264
Name:THOMAS, LAIRA LUE (FNP)
Entity Type:Individual
Prefix:
First Name:LAIRA
Middle Name:LUE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-734-3312
Mailing Address - Fax:208-734-3313
Practice Address - Street 1:401 W CAMAS AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:ID
Practice Address - Zip Code:83327
Practice Address - Country:US
Practice Address - Phone:208-764-2611
Practice Address - Fax:208-764-2646
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-327A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805065000Medicaid
ID1344624Medicare PIN
IDQ22284Medicare UPIN