Provider Demographics
NPI:1467534396
Name:MOODY, THOMAS U SR (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:U
Last Name:MOODY
Suffix:SR
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MR
Other - First Name:THOMAS
Other - Middle Name:U
Other - Last Name:MOODY
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:26775 ANABEL AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13637-3212
Mailing Address - Country:US
Mailing Address - Phone:315-629-1443
Mailing Address - Fax:
Practice Address - Street 1:21017 STATE ROUTE 12F
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1078
Practice Address - Country:US
Practice Address - Phone:315-786-3436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYOO9271363AM0700X
CT001884363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4151147OtherMVP HEALTHCARE PIN #