Basic Information
| Provider Information | |||||||||
| NPI: | 1821061805 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAXMAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | SAMUEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2690 | ||||||||
| Address2: | |||||||||
| City: | PINETOP | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859357027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283676688 | ||||||||
| FaxNumber: | 9283674916 | ||||||||
| Practice Location | |||||||||
| Address1: | 728 E WHITE MOUNTAIN BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PINETOP | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859357027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283676688 | ||||||||
| FaxNumber: | 9283674916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 11/07/2011 | ||||||||
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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 | 208D00000X | 2577 | AZ | Y | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | 2577 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BP2259718 | 01 | DEA | OTHER | 049884 | 05 | AZ | MEDICAID |