Provider Demographics
NPI:1427389097
Name:THOMPSON, ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-1415
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:580-925-2362
Practice Address - Street 1:807 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-7711
Practice Address - Country:US
Practice Address - Phone:580-332-8855
Practice Address - Fax:580-332-7374
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP-T0921363A00000X
OK2171363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2172OtherOK BOARD OF MEDICAL LICENSURE