1497120760 NPI number — MR. THADDEUS DWAYNE MITCHAM PHYSICIAN ASSISTANT

Table of content: MR. THADDEUS DWAYNE MITCHAM PHYSICIAN ASSISTANT (NPI 1497120760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497120760 NPI number — MR. THADDEUS DWAYNE MITCHAM PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITCHAM
Provider First Name:
THADDEUS
Provider Middle Name:
DWAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497120760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36TH MEDICAL GROUP
Provider Second Line Business Mailing Address:
UNIT 14010 BLDG 26012
Provider Business Mailing Address City Name:
ANDERSEN AFB
Provider Business Mailing Address State Name:
GU
Provider Business Mailing Address Postal Code:
96543-4003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
671-366-4549
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36TH MEDICAL GROUP
Provider Second Line Business Practice Location Address:
UNIT 14010 BLDG 26012
Provider Business Practice Location Address City Name:
ANDERSEN AFB
Provider Business Practice Location Address State Name:
GU
Provider Business Practice Location Address Postal Code:
96543-4003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
671-366-4549
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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