Provider Demographics
NPI:1891890547
Name:THOMAS, SALLY J
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:J
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 1:53 WOODBINE PARK
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:NY
Mailing Address - Zip Code:14454-1184
Mailing Address - Country:US
Mailing Address - Phone:585-245-8683
Mailing Address - Fax:
Practice Address - Street 1:10 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NY
Practice Address - Zip Code:14469-9312
Practice Address - Country:US
Practice Address - Phone:585-657-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330789363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR53499Medicare UPIN
NYRA9169Medicare ID - Type Unspecified