Basic Information
| Provider Information | |||||||||
| NPI: | 1063585966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 WILLOWBROOKE | ||||||||
| Address2: | |||||||||
| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656167006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178253744 | ||||||||
| FaxNumber: | 4173379730 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 NORTH MAIN | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726012926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703652000 | ||||||||
| FaxNumber: | 4173379730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 02/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 128445 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | A003106 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 174866758 | 05 | AR | MEDICAID | 5R226 | 01 | AR | AR BLUE CROSS | OTHER | 780002185 | 01 | RAILROAD MEDICARE | OTHER | 424956415 | 05 | MO | MEDICAID |