Provider Demographics
NPI:1588694152
Name:MOULAR, THOMAS H (CRNA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
Last Name:MOULAR
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 S BOWER ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-2614
Mailing Address - Country:US
Mailing Address - Phone:616-754-4691
Mailing Address - Fax:
Practice Address - Street 1:615 S BOWER ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2614
Practice Address - Country:US
Practice Address - Phone:616-754-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704072410367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4465435Medicaid
MI4594432Medicaid
MI4465435Medicaid