Provider Demographics
NPI:1063181360
Name:THOMAS, ANGEL DESHAWN (FNP-BC)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:DESHAWN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6928 CHERBOURG DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-9364
Mailing Address - Country:US
Mailing Address - Phone:260-919-5072
Mailing Address - Fax:
Practice Address - Street 1:6928 CHERBOURG DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-9364
Practice Address - Country:US
Practice Address - Phone:260-919-5072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011732A363LF0000X
IN28224831A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
INISA127A9374SOtherANTHEM