Provider Demographics
NPI:1508861865
Name:THOMPSON, ANDREA L (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:F
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 1:1444 E STEARNS ST STE 11
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-6243
Mailing Address - Country:US
Mailing Address - Phone:479-718-7546
Mailing Address - Fax:479-966-4979
Practice Address - Street 1:1444 E STEARNS ST STE 11
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-6243
Practice Address - Country:US
Practice Address - Phone:479-718-7546
Practice Address - Fax:479-966-4979
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001125363A00000X
ARPA-412363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F922P253OtherMEDICARE PA PTAN
CTP41832Medicare UPIN
AR5F922P253OtherMEDICARE PA PTAN
CT970000929Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID#