Basic Information
| Provider Information | |||||||||
| NPI: | 1619462546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | CODY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1751 VETERANS DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356304930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567183200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1751 VETERANS DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356304930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567183200 | ||||||||
| FaxNumber: | 2562463297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2018 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.1513 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 273018 | 05 | AL | MEDICAID | 271896 | 05 | AL | MEDICAID |