Provider Demographics
NPI:1629004619
Name:THOMPSON, KATHLEEN J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:J
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 1:700 S J ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1623
Mailing Address - Country:US
Mailing Address - Phone:541-947-3366
Mailing Address - Fax:541-947-4407
Practice Address - Street 1:624 S J ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1680
Practice Address - Country:US
Practice Address - Phone:541-947-3366
Practice Address - Fax:541-947-4404
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP42845Medicare UPIN