Provider Demographics
NPI:1407863061
Name:THOMAS, SANDRA (PA-C)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
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 1:12244 FLORIDA CT
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-9104
Mailing Address - Country:US
Mailing Address - Phone:772-398-1560
Mailing Address - Fax:
Practice Address - Street 1:8002 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1603
Practice Address - Country:US
Practice Address - Phone:813-880-7546
Practice Address - Fax:813-792-7895
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2278363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ23307Medicare UPIN
FLU3179ZMedicare ID - Type Unspecified