Provider Demographics
NPI:1396760930
Name:THIBODEAU, DANIEL THOMAS (PA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:THOMAS
Last Name:THIBODEAU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SENTARA CIR STE 320
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-5716
Mailing Address - Country:US
Mailing Address - Phone:757-345-4800
Mailing Address - Fax:
Practice Address - Street 1:400 SENTARA CIR STE 320
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5716
Practice Address - Country:US
Practice Address - Phone:757-345-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA011000711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0966501OtherDEA CERTIFICATE
MT0966501OtherDEA CERTIFICATE
S33516Medicare UPIN