Provider Demographics
NPI:1306073671
Name:THOMAS, MICHAEL CORNEL (APRN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CORNEL
Last Name:THOMAS
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3380
Mailing Address - Country:US
Mailing Address - Phone:801-357-7380
Mailing Address - Fax:801-357-7746
Practice Address - Street 1:3944 S 400 E
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-1600
Practice Address - Country:US
Practice Address - Phone:801-261-1442
Practice Address - Fax:801-261-9560
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56467954405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000073012Medicare UPIN