Provider Demographics
NPI:1588200463
Name:THOMPSON, ALEXIS (PA-C)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
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 1:15230 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-8107
Mailing Address - Country:US
Mailing Address - Phone:707-995-4500
Mailing Address - Fax:707-944-2401
Practice Address - Street 1:15230 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8107
Practice Address - Country:US
Practice Address - Phone:707-995-4500
Practice Address - Fax:707-944-2401
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 390200000X
CAPA64741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant