Basic Information
| Provider Information | |||||||||
| NPI: | 1184731713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARMODY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | P.A.,C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7500 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958235403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164233000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2801 K ST STE 310 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164546677 | ||||||||
| FaxNumber: | 9167338741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 03/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | OPA137830 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | OPA137830 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | OPA137830 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | GR0064540 | 05 | CA | MEDICAID | P00165306 | 01 | CA | RAILROAD MEDICARE | OTHER | ZZZ00355Z | 01 | CA | BLUE SHIELD OF CALIF. | OTHER | 170865900 | 01 | CA | US DEPT OF LABOR | OTHER |