Provider Demographics
NPI:1629080569
Name:THOMAS, TAZ (PA)
Entity Type:Individual
Prefix:
First Name:TAZ
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2432
Mailing Address - Street 2:DEPT 02
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77252-2432
Mailing Address - Country:US
Mailing Address - Phone:281-359-3223
Mailing Address - Fax:
Practice Address - Street 1:22999 HIGHWAY 59 N
Practice Address - Street 2:SUITE 272
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-4412
Practice Address - Country:US
Practice Address - Phone:281-359-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00GT99OtherBLUE CROSS BLUE SHIELD
TX00404RMedicare ID - Type Unspecified