Provider Demographics
NPI:1003626573
Name:JOHN, THOMAS ALFRED (PAC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALFRED
Last Name:JOHN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 BRONSON PKWY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8642
Mailing Address - Country:US
Mailing Address - Phone:904-673-0089
Mailing Address - Fax:
Practice Address - Street 1:211 BRONSON PKWY
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8642
Practice Address - Country:US
Practice Address - Phone:904-673-0089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9119678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant