Provider Demographics
NPI:1114156171
Name:THOMPSON, DIANE LESLIE (PA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LESLIE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17095 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-0000
Mailing Address - Country:US
Mailing Address - Phone:760-241-6666
Mailing Address - Fax:760-241-7575
Practice Address - Street 1:12550 HESPERIA ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-0000
Practice Address - Country:US
Practice Address - Phone:760-241-6666
Practice Address - Fax:760-241-7575
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19605363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant