Provider Demographics
NPI:1417338930
Name:GEORGE, THOMAS JR (DNP, CRNP, FNP-C)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:GEORGE
Suffix:JR
Gender:M
Credentials:DNP, CRNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W OAK ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1161
Mailing Address - Country:US
Mailing Address - Phone:240-308-1771
Mailing Address - Fax:
Practice Address - Street 1:555 W OAK ST STE 2
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1161
Practice Address - Country:US
Practice Address - Phone:240-308-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR216085163WC0400X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD926580503Medicaid
MDCD8143Medicare PIN
MD926580503Medicaid