Provider Demographics
NPI:1144254418
Name:JUDY, TOM ALAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:TOM
Middle Name:ALAN
Last Name:JUDY
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 1:10130 PERIMETER PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-2447
Mailing Address - Country:US
Mailing Address - Phone:888-849-7379
Mailing Address - Fax:855-857-7333
Practice Address - Street 1:10130 PERIMETER PKWY
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-2447
Practice Address - Country:US
Practice Address - Phone:888-849-7379
Practice Address - Fax:855-857-7333
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015190363A00000X
OH50003018363A00000X
NC10-95363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPOO864679OtherMEDICARE RR
OHPA35951Medicare PIN