Provider Demographics
NPI:1851534986
Name:THOMAS, SIRI SMITH (ANP)
Entity Type:Individual
Prefix:MRS
First Name:SIRI
Middle Name:SMITH
Last Name:THOMAS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MS
Other - First Name:SIRI
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-6478
Mailing Address - Fax:704-384-8182
Practice Address - Street 1:1500 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-4656
Practice Address - Country:US
Practice Address - Phone:704-384-6478
Practice Address - Fax:704-384-8182
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006622363LA2200X, 363L00000X
SC3723363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1701Medicaid
SCAA41999296Medicare PIN