Provider Demographics
NPI:1467665349
Name:THOMPSON, THOMAS (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
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:PO BOX 2066
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34460-2066
Mailing Address - Country:US
Mailing Address - Phone:352-563-0931
Mailing Address - Fax:
Practice Address - Street 1:1907 HIGHWAY 44 W
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-3801
Practice Address - Country:US
Practice Address - Phone:352-344-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111242700Medicaid