Basic Information
| Provider Information | |||||||||
| NPI: | 1285692137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | NORMAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11790 SW BARNES RD BLDG A | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036432100 | ||||||||
| FaxNumber: | 5036437300 | ||||||||
| Practice Location | |||||||||
| Address1: | 11790 SW BARNES RD BLDG A | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036432100 | ||||||||
| FaxNumber: | 5036437300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 06/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD15689 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 021993005 | 01 | OR | BLUE CROSS | OTHER | 301242 | 01 | OR | PROVIDENCE HEALTH PLAN | OTHER | 054499 | 05 | OR | MEDICAID | 93112982997006A004 | 01 | TRI WEST | OTHER |