Basic Information
Provider Information | |||||||||
NPI: | 1730146242 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TALBOT | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | MARTIN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 43160 | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857333160 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207223777 | ||||||||
FaxNumber: | 5202966224 | ||||||||
Practice Location | |||||||||
Address1: | VA MEDICAL CENTER-PRIMARY CARE/MESQUITE CLINIC | ||||||||
Address2: | 3601 S. 6TH AVE | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857230001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207926832 | ||||||||
FaxNumber: | 5206294768 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2006 | ||||||||
LastUpdateDate: | 12/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP1719 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | F0899545 | 01 | AZ | NP CERTIFICATION-AANP | OTHER | RN122045 | 01 | AZ | RN LICENSE | OTHER | AP1719 | 01 | AZ | FNP-AZ-RX/DISPENSING | OTHER | MT1071997 | 01 | AS | DEA | OTHER |