Provider Demographics
NPI:1770964934
Name:THOMAS, TANYA A (NP)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:A
Last Name:THOMAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:A
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:78 SOUTHERN GOLF CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-8008
Mailing Address - Country:US
Mailing Address - Phone:678-472-4386
Mailing Address - Fax:
Practice Address - Street 1:78 SOUTHERN GOLF CT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-8008
Practice Address - Country:US
Practice Address - Phone:678-472-4386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-13
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177598363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily