Provider Demographics
NPI:1871360149
Name:THOMAS, MYRISSA LARA (APRN)
Entity type:Individual
Prefix:
First Name:MYRISSA
Middle Name:LARA
Last Name:THOMAS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MYRISSA
Other - Middle Name:LARA
Other - Last Name:GOSSARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 996
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:UT
Mailing Address - Zip Code:84634-0996
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 E 100 S
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:UT
Practice Address - Zip Code:84634-0996
Practice Address - Country:US
Practice Address - Phone:435-558-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11295565-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner