Provider Demographics
NPI:1104691393
Name:THOMAS, ANDRA RENA'
Entity type:Individual
Prefix:
First Name:ANDRA
Middle Name:RENA'
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 NE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4439
Mailing Address - Country:US
Mailing Address - Phone:918-201-4333
Mailing Address - Fax:
Practice Address - Street 1:215 NE 1ST ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4439
Practice Address - Country:US
Practice Address - Phone:918-201-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist