Provider Demographics
NPI:1629018916
Name:THOMPSON, GARY C (PAC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:C
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1772 BLAIR LOOP RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-5013
Mailing Address - Country:US
Mailing Address - Phone:434-822-0339
Mailing Address - Fax:434-797-2514
Practice Address - Street 1:109 BRIDGE ST STE 300
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1222
Practice Address - Country:US
Practice Address - Phone:434-793-4711
Practice Address - Fax:434-797-2514
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110000067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008954542Medicaid
VA970003213OtherRR MEDICARE PIN
VA0786860001Medicare NSC
VA970000028Medicare PIN
VAR65376Medicare UPIN