Basic Information
| Provider Information | |||||||||
| NPI: | 1003012287 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMASON | ||||||||
| FirstName: | BRENDA | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3801 DEBORAH DR | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712012111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183235688 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3510 MAGNOLIA CV | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712032372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183231100 | ||||||||
| FaxNumber: | 3183231161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1664821 | 05 | LA | MEDICAID | 1442399 | 01 | LA | TDK AMC GROUP AID PROVIDE | OTHER |