Provider Demographics
NPI:1982592192
Name:THOMAS, MICHAEL RYAN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RYAN
Last Name:THOMAS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9006 SUNDANCE LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7788
Mailing Address - Country:US
Mailing Address - Phone:318-990-9932
Mailing Address - Fax:
Practice Address - Street 1:912 S PECAN ST
Practice Address - Street 2:
Practice Address - City:VIVIAN
Practice Address - State:LA
Practice Address - Zip Code:71082-3350
Practice Address - Country:US
Practice Address - Phone:318-375-2203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA242109363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily