Provider Demographics
NPI:1487483020
Name:GOLDRICK, THOMAS MICHAEL (RPA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:GOLDRICK
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DOROTHY DR
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-3715
Mailing Address - Country:US
Mailing Address - Phone:516-650-0733
Mailing Address - Fax:
Practice Address - Street 1:290 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2916
Practice Address - Country:US
Practice Address - Phone:631-361-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant