Provider Demographics
NPI:1588312680
Name:THOMAS, EVAN R (PA)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:R
Last Name:THOMAS
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 1:8207 113TH ST
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4128
Mailing Address - Country:US
Mailing Address - Phone:727-397-3991
Mailing Address - Fax:
Practice Address - Street 1:1700 66TH ST N STE 510
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5512
Practice Address - Country:US
Practice Address - Phone:727-384-2479
Practice Address - Fax:727-345-2300
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115388363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical