Provider Demographics
NPI:1275635997
Name:THOMPSON, GARY D (CPO/LPO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:CPO/LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 W NOB HILL BLVD UNIT 1
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-5500
Mailing Address - Country:US
Mailing Address - Phone:509-249-0011
Mailing Address - Fax:509-249-0077
Practice Address - Street 1:502 W NOB HILL BLVD UNIT 1
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-5500
Practice Address - Country:US
Practice Address - Phone:509-249-0011
Practice Address - Fax:509-249-0077
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS00000366/OI0000038174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9058124Medicaid
WA9058124Medicaid