Provider Demographics
NPI:1386228583
Name:THOMPSON, COREY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33528 600TH AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MN
Mailing Address - Zip Code:55982-7681
Mailing Address - Country:US
Mailing Address - Phone:507-279-2510
Mailing Address - Fax:
Practice Address - Street 1:33528 600TH AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MN
Practice Address - Zip Code:55982-7681
Practice Address - Country:US
Practice Address - Phone:507-279-2510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant