Provider Demographics
NPI:1497120760
Name:MITCHAM, THADDEUS DWAYNE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:THADDEUS
Middle Name:DWAYNE
Last Name:MITCHAM
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Gender:M
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:36TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 14010 BLDG 26012
Mailing Address - City:ANDERSEN AFB
Mailing Address - State:GU
Mailing Address - Zip Code:96543-4003
Mailing Address - Country:US
Mailing Address - Phone:671-366-4549
Mailing Address - Fax:
Practice Address - Street 1:36TH MEDICAL GROUP
Practice Address - Street 2:UNIT 14010 BLDG 26012
Practice Address - City:ANDERSEN AFB
Practice Address - State:GU
Practice Address - Zip Code:96543-4003
Practice Address - Country:US
Practice Address - Phone:671-366-4549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2024-08-14
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant