Provider Demographics
NPI:1518652296
Name:THOMPSON, NATHANIEL MARK
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:MARK
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BECKETT HALL CIR APT 211
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5212
Mailing Address - Country:US
Mailing Address - Phone:530-966-3362
Mailing Address - Fax:
Practice Address - Street 1:811 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3466
Practice Address - Country:US
Practice Address - Phone:916-922-9868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker