Provider Demographics
NPI:1427227990
Name:THOMAS, DEANDRA MEDORA
Entity type:Individual
Prefix:
First Name:DEANDRA
Middle Name:MEDORA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 UNIVERSITY DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-1885
Mailing Address - Country:US
Mailing Address - Phone:248-373-2720
Mailing Address - Fax:248-373-3080
Practice Address - Street 1:989 UNIVERSITY DR
Practice Address - Street 2:SUITE 105
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-1885
Practice Address - Country:US
Practice Address - Phone:248-373-2720
Practice Address - Fax:248-373-3080
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005182363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant