Provider Demographics
NPI:1518722503
Name:THOMPSON, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20301 WILCHER CT
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-6844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:460 S MAIN ST # 302
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-8006
Practice Address - Country:US
Practice Address - Phone:704-255-6383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP22890208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation