Provider Demographics
NPI:1780637280
Name:BOHANON, THOMAS JERRY JR (PT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JERRY
Last Name:BOHANON
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5437 WINTERGREEN RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9236
Mailing Address - Country:US
Mailing Address - Phone:804-756-8490
Mailing Address - Fax:
Practice Address - Street 1:3001 HUNGARY SPRING RD
Practice Address - Street 2:SUITE D
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-2428
Practice Address - Country:US
Practice Address - Phone:804-756-8490
Practice Address - Fax:804-756-8494
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202912225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist