Provider Demographics
NPI:1972120525
Name:THREADGILL, TOMIEKO (PHLEBO, MA, CMLA)
Entity type:Individual
Prefix:MS
First Name:TOMIEKO
Middle Name:
Last Name:THREADGILL
Suffix:
Gender:F
Credentials:PHLEBO, MA, CMLA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 E PASS RD STE J
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3261
Mailing Address - Country:US
Mailing Address - Phone:228-284-4176
Mailing Address - Fax:228-284-5724
Practice Address - Street 1:549 E PASS RD STE J
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-3261
Practice Address - Country:US
Practice Address - Phone:228-284-4176
Practice Address - Fax:228-284-5724
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS279306374700000X, 246RP1900X, 246RM2200X
MS25D2232943291U00000X, 247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No374700000XNursing Service Related ProvidersTechnician
No291U00000XLaboratoriesClinical Medical Laboratory
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS002200921Medicaid