Provider Demographics
NPI:1962872200
Name:AHEARN, THOMAS JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:AHEARN
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 1:450 W FOOTHILL BLVD
Mailing Address - Street 2:#30
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1068
Mailing Address - Country:US
Mailing Address - Phone:815-830-0914
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1128403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant