Provider Demographics
NPI:1417555863
Name:THOMAS, JESSICA GAGE (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:GAGE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:GAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:158 ELLSWORTH MANOR DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-9861
Mailing Address - Country:US
Mailing Address - Phone:336-953-3104
Mailing Address - Fax:
Practice Address - Street 1:3604 SHANNON RD STE 200
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6343
Practice Address - Country:US
Practice Address - Phone:336-953-3104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11184363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program