Basic Information
| Provider Information | |||||||||
| NPI: | 1841290624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEXTON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | NATHAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5601 NE ANTIOCH RD | ||||||||
| Address2: | STE 7 | ||||||||
| City: | GLADSTONE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641192302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164551155 | ||||||||
| FaxNumber: | 8164551161 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 NE ANTIOCH RD | ||||||||
| Address2: | STE 7 | ||||||||
| City: | GLADSTONE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641192302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164551155 | ||||||||
| FaxNumber: | 8164551161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 12-00278 | KS | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 000576 | MO | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 8338922 | 01 | MO | MISSOURI MEDICARE | OTHER |