Provider Demographics
NPI:1073334439
Name:THOMAS, TREVOR LEE (OPTICIAN)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:LEE
Last Name:THOMAS
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4012
Mailing Address - Country:US
Mailing Address - Phone:414-226-6619
Mailing Address - Fax:
Practice Address - Street 1:1401 S 108TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-4012
Practice Address - Country:US
Practice Address - Phone:414-226-6619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician