Provider Demographics
NPI:1558472340
Name:CHASE, THOMAS J (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:CHASE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 PIER AVE
Mailing Address - Street 2:SUITE B301
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3949
Mailing Address - Country:US
Mailing Address - Phone:424-634-2993
Mailing Address - Fax:
Practice Address - Street 1:703 PIER AVE
Practice Address - Street 2:SUITE B301
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3949
Practice Address - Country:US
Practice Address - Phone:424-634-2993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18523363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18523OtherCALIFORNIA LICENSE