Provider Demographics
NPI:1063863876
Name:THOMPSON, BRENT LEE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:LEE
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84104-3539
Mailing Address - Country:US
Mailing Address - Phone:801-973-2588
Mailing Address - Fax:801-973-6985
Practice Address - Street 1:441 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84104-3539
Practice Address - Country:US
Practice Address - Phone:801-973-2588
Practice Address - Fax:801-973-6985
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8021622-8900363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care