Provider Demographics
NPI:1932184926
Name:DISTEL, THOMAS WAYNE (PA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:WAYNE
Last Name:DISTEL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 360
Mailing Address - Street 2:102 SOUTH ARCHER
Mailing Address - City:HENRIETTA
Mailing Address - State:TX
Mailing Address - Zip Code:76365-0360
Mailing Address - Country:US
Mailing Address - Phone:940-538-4336
Mailing Address - Fax:940-538-6271
Practice Address - Street 1:102 S ARCHER ST
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:TX
Practice Address - Zip Code:76365-2746
Practice Address - Country:US
Practice Address - Phone:940-538-4336
Practice Address - Fax:940-538-6271
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA01207OtherST PA LICENSE
R92687Medicare UPIN
TX87N409Medicare ID - Type Unspecified