Provider Demographics
NPI:1265558498
Name:PELUSO, THOMAS M (PA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:PELUSO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 TEJAS PL
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9123
Mailing Address - Country:US
Mailing Address - Phone:805-929-3211
Mailing Address - Fax:805-929-6440
Practice Address - Street 1:7512 MORRO RD
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4404
Practice Address - Country:US
Practice Address - Phone:805-792-1400
Practice Address - Fax:805-792-1485
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11945363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1508COtherMEDICARE GROUP PLAN-ATASCADERO
CABC021ZOtherPTAN
CAW1508AOtherMEDICARE GROUP PLAN-TEMPLETON
CA1275550295OtherNPI-CHCCC TEMPLETON
CA1073533089OtherNPI - ATASCADERO