Provider Demographics
NPI:1235866740
Name:THOMPSON, OWEN RICHARD
Entity Type:Individual
Prefix:
First Name:OWEN
Middle Name:RICHARD
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 1:4225 GENESEE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1994
Mailing Address - Country:US
Mailing Address - Phone:716-204-3200
Mailing Address - Fax:716-204-4337
Practice Address - Street 1:5959 BIG TREE RD STE 108
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2291
Practice Address - Country:US
Practice Address - Phone:716-204-3200
Practice Address - Fax:716-204-4337
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028448363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant