Provider Demographics
NPI:1730212580
Name:SQUIRES, THOMAS ROBERT
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROBERT
Last Name:SQUIRES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 COTTAGE AVE W APT 24
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 160
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1839
Practice Address - Country:US
Practice Address - Phone:651-917-3634
Practice Address - Fax:651-917-3620
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant