Provider Demographics
NPI:1912979535
Name:THOMAS, DERRELL MURRELL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DERRELL
Middle Name:MURRELL
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJP EMERGENCY MEDICINE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-4405
Practice Address - Fax:904-244-4508
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA3361363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2910501-00Medicaid
FL970021238Medicare PIN
FLE0706Medicare PIN
FLS55452Medicare UPIN