Provider Demographics
NPI:1043282890
Name:HINES, THOMAS JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:HINES
Suffix:
Gender:M
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 1:25 W CRYSTAL LAKE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-4475
Mailing Address - Country:US
Mailing Address - Phone:407-254-2500
Mailing Address - Fax:407-423-2789
Practice Address - Street 1:45 W CRYSTAL LAKE ST
Practice Address - Street 2:SUITE 197
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4435
Practice Address - Country:US
Practice Address - Phone:407-254-2510
Practice Address - Fax:407-423-2789
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105044363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCE019YMedicare PIN
FL003298500Medicaid