Provider Demographics
NPI:1912099748
Name:AHERN, THOMAS R (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:AHERN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 LINDSAY LN
Mailing Address - Street 2:STE B
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4103
Mailing Address - Country:US
Mailing Address - Phone:307-578-1953
Mailing Address - Fax:307-578-1956
Practice Address - Street 1:720 LINDSAY LN
Practice Address - Street 2:STE B
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4103
Practice Address - Country:US
Practice Address - Phone:307-578-1953
Practice Address - Fax:307-578-1956
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WYTL390363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant