Doctor Name: | THOMAS STALLWORTH |
NPI Number: | 1528486289 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | ARNP |
License Number: | 9331690 |
Business Practice Address: | 301 Fisher St Pediatric Clinic Keesler Afb, MS - 395342508 |
Business Phone Number: | 2283763437 |
Business Fax Number: | 2283760198 |
Mailing Address: | 301 Fisher St, Pediatric Clinic KEESLER AFB |
State: | MS |
Postal Code: | 395342508 |
Phone Number: | 2283763437 |
Fax Number: | 2283760198 |
NPI Enumeration Date: | 03/31/2014 |
NPI Last Update Date: | 03/31/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LP0200X |
License Number: | 9331690 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | FL |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Pediatrics |
Taxonomy Definition: |