Provider Demographics
NPI:1669634390
Name:THOMAS, AMANDA A
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:A
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15959 HALL RD
Mailing Address - Street 2:SUITE LL 104
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044
Mailing Address - Country:US
Mailing Address - Phone:586-799-1212
Mailing Address - Fax:
Practice Address - Street 1:48681 HAYES RD
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48315-4403
Practice Address - Country:US
Practice Address - Phone:586-799-1212
Practice Address - Fax:586-799-1210
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383120356OtherTAX IDENTIFICATION
MIAT005259OtherLICENSE NUMBER