Provider Demographics
NPI:1477289916
Name:THOMPSON, MATHEW RAY (CRNA)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:RAY
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4881 SUGAR MAPLE DR.
Mailing Address - Street 2:
Mailing Address - City:WRIGHT PATTERSON AFB, OHIO
Mailing Address - State:OH
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:618-204-0029
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:618-204-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0020585367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered