MEDICARE: MR. TOM ALAN JUDY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	015190	NY
2	363A00000X	Physician Assistant	50003018	OH
3	363AM0700X	Medical Physician Assistant	10-95	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	POO864679	OTHER	OH	MEDICARE RR

General Provider Information

NPI Number	:	1144254418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TOM ALAN JUDY PA-C

Provider Business Mailing Address
First Line	:	10130 PERIMETER PKWY
Second Line	:	STE 200
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-2447
Country	:	US
Telephone Number	:	888-849-7379
Fax Number	:	855-857-7333

Provider Business Practice Location Address
First Line	:	10130 PERIMETER PKWY
Second Line	:	STE 200
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-2447
Country	:	US
Telephone Number	:	888-849-7379
Fax Number	:	855-857-7333

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	02/10/2017

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Directions to “ MR. TOM ALAN JUDY PA-C” Practice Location

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