Basic Information
| Provider Information | |||||||||
| NPI: | 1558322693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | TUDUR | ||||||||
| MiddleName: | GWYN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2205 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756523515 | ||||||||
| FaxNumber: | 5756523518 | ||||||||
| Practice Location | |||||||||
| Address1: | 2205 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756523515 | ||||||||
| FaxNumber: | 5756523518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1564 | NM | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000S8096 | 05 | NM | MEDICAID |