Provider Demographics
NPI:1528416005
Name:THOMPSON, CASEY JEAN
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:JEAN
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 1:8237 ROCHESTER AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0716
Mailing Address - Country:US
Mailing Address - Phone:909-477-3310
Mailing Address - Fax:
Practice Address - Street 1:8237 ROCHESTER AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0716
Practice Address - Country:US
Practice Address - Phone:909-477-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53744363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant