Provider Demographics
NPI:1205192788
Name:THOMPSON, AGNIESZKA KUBICA (MD)
Entity Type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:KUBICA
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AGNIESZKA
Other - Middle Name:
Other - Last Name:KUBICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:425 PINE RIDGE BLVD STE 305A
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4124
Mailing Address - Country:US
Mailing Address - Phone:715-847-2626
Mailing Address - Fax:
Practice Address - Street 1:425 PINE RIDGE BLVD STE 305A
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4124
Practice Address - Country:US
Practice Address - Phone:715-847-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56966207N00000X
WI67696-20207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400101191Medicare PIN