Basic Information
| Provider Information | |||||||||
| NPI: | 1053667444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | B | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | BACON | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | CATHERINE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012273255 | ||||||||
| FaxNumber: | 9012273205 | ||||||||
| Practice Location | |||||||||
| Address1: | 6250 OLD CANTON RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392112946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019567280 | ||||||||
| FaxNumber: | 6019776244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2012 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT2365 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 02986263 | 05 | MS | MEDICAID |