Provider Demographics
NPI:1669863155
Name:FALLON, THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:FALLON
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 1:8927 US HIGHWAY 301 N STE 210
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-8701
Mailing Address - Country:US
Mailing Address - Phone:941-845-4652
Mailing Address - Fax:941-845-4654
Practice Address - Street 1:8927 US HIGHWAY 301 N STE 210
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-8701
Practice Address - Country:US
Practice Address - Phone:941-845-4652
Practice Address - Fax:941-845-4654
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108432363A00000X
CA55154363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant