Provider Demographics
NPI:1992080550
Name:MCKIERNAN, THOMAS SCOTT JR
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:SCOTT
Last Name:MCKIERNAN
Suffix:JR
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 1:611 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6156
Mailing Address - Country:US
Mailing Address - Phone:209-577-1014
Mailing Address - Fax:209-577-8046
Practice Address - Street 1:611 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6156
Practice Address - Country:US
Practice Address - Phone:209-577-1014
Practice Address - Fax:209-577-8046
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA6031237700000X
COHAD0000247237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist