Provider Demographics
NPI:1386125607
Name:MYRON, THOMAS NEIL
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:NEIL
Last Name:MYRON
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 1:7349 HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-8155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:246 HALEY DR
Practice Address - Street 2:
Practice Address - City:CENTER
Practice Address - State:TX
Practice Address - Zip Code:75935-9798
Practice Address - Country:US
Practice Address - Phone:936-598-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2073472225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2073472OtherPTA