Provider Demographics
NPI:1598966079
Name:COLIVAS, THOMAS JAMES (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES
Last Name:COLIVAS
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 1:1556 PRIMA CT
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-3147
Mailing Address - Country:US
Mailing Address - Phone:818-838-3565
Mailing Address - Fax:
Practice Address - Street 1:211 S MACLAY AVE
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-3603
Practice Address - Country:US
Practice Address - Phone:818-700-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA113333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MC1099159OtherDEA