Provider Demographics
NPI:1538223912
Name:TROTTER, THOM (PA)
Entity type:Individual
Prefix:
First Name:THOM
Middle Name:
Last Name:TROTTER
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 1:810 ROSITA RD
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-5616
Mailing Address - Country:US
Mailing Address - Phone:831-393-0522
Mailing Address - Fax:
Practice Address - Street 1:1555 SOQUEL DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1705
Practice Address - Country:US
Practice Address - Phone:831-462-7730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15133363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15133Medicaid
CAPA15133Medicaid
0PA151331Medicare PIN
P00215452Medicare PIN