Provider Demographics
NPI:1336361443
Name:THOMAS, GERALD L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:L
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:44555 WOODWARD AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5031
Mailing Address - Country:US
Mailing Address - Phone:248-335-2977
Mailing Address - Fax:248-858-3880
Practice Address - Street 1:44555 WOODWARD AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5031
Practice Address - Country:US
Practice Address - Phone:248-335-2977
Practice Address - Fax:248-858-3880
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003758363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00135174OtherRAILROAD MEDICARE
MIP00135174OtherRAILROAD MEDICARE