Provider Demographics
NPI:1649766114
Name:BALES, THOMAS BENJAMIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:BENJAMIN
Last Name:BALES
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 1:4631 TELLER AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8105
Mailing Address - Country:US
Mailing Address - Phone:949-887-7187
Mailing Address - Fax:949-476-3080
Practice Address - Street 1:345 BLACKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4800
Practice Address - Country:US
Practice Address - Phone:401-455-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-07
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58355363A00000X
RIPA01031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant