Provider Demographics
NPI:1932665106
Name:THIBODEAUX, TAMARA M (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:M
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 769787
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-9363
Mailing Address - Country:US
Mailing Address - Phone:910-260-8397
Mailing Address - Fax:
Practice Address - Street 1:7333 POTRANCO RD APT 7103
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-2260
Practice Address - Country:US
Practice Address - Phone:910-260-8397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140186363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily