Provider Demographics
NPI:1447838115
Name:THOMAS, ELIZABETH CANDLER GREGORY
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CANDLER GREGORY
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3334 HIGHWAY 155
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-3513
Mailing Address - Country:US
Mailing Address - Phone:770-305-7929
Mailing Address - Fax:770-305-7969
Practice Address - Street 1:3334 HIGHWAY 155
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-3513
Practice Address - Country:US
Practice Address - Phone:770-305-7929
Practice Address - Fax:770-305-7969
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant