Provider Demographics
NPI:1376520684
Name:GALISIN, THOMAS JOHN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JOHN
Last Name:GALISIN
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 1:2906 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-1921
Mailing Address - Country:US
Mailing Address - Phone:252-823-7212
Mailing Address - Fax:252-641-7286
Practice Address - Street 1:2906 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-1921
Practice Address - Country:US
Practice Address - Phone:252-823-7212
Practice Address - Fax:252-641-7286
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2761312AMedicare ID - Type Unspecified
NCS67995Medicare UPIN
NC2761312Medicare ID - Type Unspecified