Basic Information
| Provider Information | |||||||||
| NPI: | 1679523617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | JONATHAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34120 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895334120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757475050 | ||||||||
| FaxNumber: | 7757475005 | ||||||||
| Practice Location | |||||||||
| Address1: | 10121 PINE AVE | ||||||||
| Address2: | |||||||||
| City: | TRUCKEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961614835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305876011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 09/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G58233 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G582331 | 05 | CA | MEDICAID |