Provider Demographics
NPI:1851686182
Name:DOUGLAS, THOMAS G (NP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 N NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-4306
Mailing Address - Country:US
Mailing Address - Phone:417-837-4000
Mailing Address - Fax:417-875-4710
Practice Address - Street 1:108 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1407
Practice Address - Country:US
Practice Address - Phone:417-466-4110
Practice Address - Fax:417-466-4255
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011016629363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily