Provider Demographics
NPI:1679501597
Name:THOMAS, JUDITH SELFRIDGE (NP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:SELFRIDGE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-9718
Mailing Address - Country:US
Mailing Address - Phone:805-641-3483
Mailing Address - Fax:805-641-3870
Practice Address - Street 1:1300 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3505
Practice Address - Country:US
Practice Address - Phone:310-514-5350
Practice Address - Fax:310-514-5421
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP7106363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN262576Medicaid
CAP20495Medicare UPIN
CAWNP7106BMedicare PIN