Basic Information
| Provider Information | |||||||||
| NPI: | 1508840828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | TRESARAE | ||||||||
| MiddleName: | SHAWN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PATE LANE | ||||||||
| OtherFirstName: | TRESARAE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.A.C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2570 TURNPIKE RD | ||||||||
| Address2: | |||||||||
| City: | ALBERTVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359500501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565723271 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2505 US HIGHWAY 431 | ||||||||
| Address2: | |||||||||
| City: | BOAZ | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565938310 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 09/25/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-430 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 009933282 | 05 | AL | MEDICAID | PA-430 | 01 | AL | ALABAMA STATE LICENSE | OTHER |