Provider Demographics
NPI:1477225340
Name:THOMAS, MITSPA
Entity type:Individual
Prefix:
First Name:MITSPA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 OLD JEFFERSON RD BLDG 800
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-1400
Mailing Address - Country:US
Mailing Address - Phone:706-353-2290
Mailing Address - Fax:706-353-2992
Practice Address - Street 1:1460 RESURGENCE DR
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7320
Practice Address - Country:US
Practice Address - Phone:706-515-2410
Practice Address - Fax:706-353-2992
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN311227363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily