Provider Demographics
NPI:1114053881
Name:THOMPSON, ROLAND LEE
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:LEE
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 N ROAD 72
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-1919
Mailing Address - Country:US
Mailing Address - Phone:509-545-1416
Mailing Address - Fax:509-545-1430
Practice Address - Street 1:2820 N ROAD 72
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-1919
Practice Address - Country:US
Practice Address - Phone:509-545-1416
Practice Address - Fax:509-545-1430
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9053018163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9053018Medicaid