Provider Demographics
NPI:1811233794
Name:THOMAS, MARK SHANNON
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:SHANNON
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:SHANNON
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2055 GEES MILL RD NE STE 313
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-1363
Mailing Address - Country:US
Mailing Address - Phone:770-689-9788
Mailing Address - Fax:
Practice Address - Street 1:2124 FOUNTAIN SQ
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3196
Practice Address - Country:US
Practice Address - Phone:770-689-9788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist