Provider Demographics
NPI:1841307212
Name:ELLIOTT, THOMAS AMOS
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:AMOS
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POB 1191
Mailing Address - Street 2:1113 DAINGERFIELD STREET
Mailing Address - City:TAPPAHANNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22560-1191
Mailing Address - Country:US
Mailing Address - Phone:571-501-8865
Mailing Address - Fax:
Practice Address - Street 1:POB 1191
Practice Address - Street 2:1113 DAINGERFIELD ST
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-1191
Practice Address - Country:US
Practice Address - Phone:703-861-4997
Practice Address - Fax:804-445-1914
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705057306171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010029759OtherPROVIDER #