Provider Demographics
NPI:1730607722
Name:SHADDIX, THOMAS JOSEPH (PA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:SHADDIX
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MARJORIE PL
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-8048
Mailing Address - Country:US
Mailing Address - Phone:859-979-5482
Mailing Address - Fax:
Practice Address - Street 1:1354 BULL LEA RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-1247
Practice Address - Country:US
Practice Address - Phone:859-562-3899
Practice Address - Fax:859-257-6200
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2304363AM0700X, 363AS0400X, 363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical