Basic Information
| Provider Information | |||||||||
| NPI: | 1598743494 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOM | ||||||||
| FirstName: | JEAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 GOLF COURSE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557448648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183265000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1601 GOLF COURSE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557448648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183265000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 169566-22 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 913542100 | 05 | MN | MEDICAID |