Basic Information
| Provider Information | |||||||||
| NPI: | 1538152657 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9476 TRILLIUM DR | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148425848 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2315 DOUGHERTY FERRY RD STE 205 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631223383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149779600 | ||||||||
| FaxNumber: | 3149779600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 01/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2001016022 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.