Provider Demographics
NPI:1659370476
Name:GIVENS, THOMAS G (PAC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:GIVENS
Suffix:
Gender:M
Credentials:PAC
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 20828
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86439-0828
Mailing Address - Country:US
Mailing Address - Phone:928-763-2001
Mailing Address - Fax:928-763-2038
Practice Address - Street 1:3015 HIGHWAY 95
Practice Address - Street 2:SUITE 105
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-4334
Practice Address - Country:US
Practice Address - Phone:928-763-2001
Practice Address - Fax:928-763-2038
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3004363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ872798Medicaid
S66561Medicare UPIN
AZ872798Medicare ID - Type Unspecified