1629382924 NPI number — LATASHA N THOMAS

Table of content: LATASHA N THOMAS (NPI 1629382924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629382924 NPI number — LATASHA N THOMAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMAS
Provider First Name:
LATASHA
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PEACE
Provider Other First Name:
LATASHA
Provider Other Middle Name:
N
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629382924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 SAINT PATRICKS DR
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
WALDORF
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20603-4527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-870-7366
Provider Business Mailing Address Fax Number:
301-870-6717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10401 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20735-3110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-856-0050
Provider Business Practice Location Address Fax Number:
301-856-0518
Provider Enumeration Date:
07/29/2010

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: 225100000X , with the licence number:  23374 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 196518200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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