Provider Demographics
NPI:1962465211
Name:DERNBACH, THOMAS JOHN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JOHN
Last Name:DERNBACH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 NE NEFF RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4281
Mailing Address - Country:US
Mailing Address - Phone:541-382-3344
Mailing Address - Fax:541-322-2286
Practice Address - Street 1:2200 NE NEFF RD STE 200
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4281
Practice Address - Country:US
Practice Address - Phone:541-382-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500616698Medicaid
R158147Medicare PIN