Provider Demographics
NPI:1700482361
Name:ODDO, THANNA NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:THANNA
Middle Name:NICOLE
Last Name:ODDO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 DEL PRADO BLVD S
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-2660
Mailing Address - Country:US
Mailing Address - Phone:239-772-4484
Mailing Address - Fax:
Practice Address - Street 1:657 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2660
Practice Address - Country:US
Practice Address - Phone:239-772-4484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062034363A00000X
FLPA9115197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant