Basic Information
| Provider Information | |||||||||
| NPI: | 1568136117 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 KRESGE WAY STE 308 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028958911 | ||||||||
| FaxNumber: | 5028958977 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 KRESGE WAY STE 308 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028958911 | ||||||||
| FaxNumber: | 5028958977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2021 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 3015149 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 3015149 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.