Provider Demographics
NPI:1124751011
Name:FICKETT, THOMAS STEPHEN
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:STEPHEN
Last Name:FICKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1894 MERCHANTS ROW BLVD APT 626
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-8875
Mailing Address - Country:US
Mailing Address - Phone:850-728-4765
Mailing Address - Fax:
Practice Address - Street 1:2173 CENTERVILLE PL STE A
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8303
Practice Address - Country:US
Practice Address - Phone:850-385-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA759367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant