Provider Demographics
NPI:1740590314
Name:THOMAS, ASHLEY NICHOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICHOLE
Last Name:THOMAS
Suffix:
Gender:F
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 1:6286 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-2207
Mailing Address - Country:US
Mailing Address - Phone:208-766-6570
Mailing Address - Fax:
Practice Address - Street 1:710 E. ALICE STREET
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221
Practice Address - Country:US
Practice Address - Phone:208-785-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant