Provider Demographics
NPI:1184731713
Name:CARMODY, THOMAS C (PA,C)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:CARMODY
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 1:7500 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-5403
Mailing Address - Country:US
Mailing Address - Phone:916-423-3000
Mailing Address - Fax:
Practice Address - Street 1:2801 K ST STE 310
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5119
Practice Address - Country:US
Practice Address - Phone:916-454-6677
Practice Address - Fax:916-733-8741
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPA137830363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0064540Medicaid
CAP00165306OtherRAILROAD MEDICARE
CAZZZ00355ZOtherBLUE SHIELD OF CALIF.
CA170865900OtherUS DEPT OF LABOR
CAS63917Medicare UPIN
CAZZZ00355ZMedicare ID - Type Unspecified