Provider Demographics
NPI:1811004831
Name:THOMAS, MARY CAROLYN (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAROLYN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:THOMAS
Other - Last Name:BECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 BARRET AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1733
Mailing Address - Country:US
Mailing Address - Phone:502-587-0111
Mailing Address - Fax:502-587-9112
Practice Address - Street 1:801 BARRET AVE STE 210
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1733
Practice Address - Country:US
Practice Address - Phone:502-587-0111
Practice Address - Fax:502-587-9112
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2025P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7800403300Medicaid
KYP33643Medicare UPIN
KY7800403300Medicaid
KY0675004Medicare PIN