Provider Demographics
NPI:1841223807
Name:KOLT, THOMAS LAROY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:LAROY
Last Name:KOLT
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 1:22431 ANTONIO PKWY # B160-613
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2804
Mailing Address - Country:US
Mailing Address - Phone:855-727-2251
Mailing Address - Fax:855-727-2251
Practice Address - Street 1:22431 ANTONIO PKWY # B160-613
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2804
Practice Address - Country:US
Practice Address - Phone:855-727-2251
Practice Address - Fax:855-727-2251
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11655208G00000X, 363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11655OtherPHYSICIAN ASSISTANT
CAWPA11655Medicare ID - Type Unspecified