Provider Demographics
NPI:1033735063
Name:THOMPSON, EVAN ROBERT (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:ROBERT
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 CHEYENNE LN
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-8822
Mailing Address - Country:US
Mailing Address - Phone:406-396-5764
Mailing Address - Fax:
Practice Address - Street 1:2825 STOCKYARD RD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1503
Practice Address - Country:US
Practice Address - Phone:406-201-7142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-159929363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health