Provider Demographics
NPI:1609955285
Name:KU, TOM (PA-C)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:KU
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:PO BOX 5089
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-8003
Mailing Address - Country:US
Mailing Address - Phone:951-371-2703
Mailing Address - Fax:951-735-3296
Practice Address - Street 1:2250 S MAIN ST
Practice Address - Street 2:STE. 106
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-2534
Practice Address - Country:US
Practice Address - Phone:951-371-2703
Practice Address - Fax:951-735-3296
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12649363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMK0550308OtherDEA LIC#