Provider Demographics
NPI:1619169919
Name:THOMPSON, HEATHER (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2120 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-2221
Mailing Address - Country:US
Mailing Address - Phone:972-438-4636
Mailing Address - Fax:972-438-6585
Practice Address - Street 1:2120 N MACARTHUR BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2221
Practice Address - Country:US
Practice Address - Phone:972-438-4636
Practice Address - Fax:972-438-6585
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17901363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17901OtherPA LICENSE
CAPA17901OtherPA LICENSE