Provider Demographics
NPI:1639176001
Name:THOMPSON, BRIAN S (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:S
Last Name:THOMPSON
Suffix:
Gender:M
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 1:7257 NW 4TH BLVD
Mailing Address - Street 2:SUITE # 303
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-1600
Mailing Address - Country:US
Mailing Address - Phone:352-474-2664
Mailing Address - Fax:
Practice Address - Street 1:7257 NW 4TH BLVD
Practice Address - Street 2:SUITE # 303
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-1600
Practice Address - Country:US
Practice Address - Phone:352-474-2664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2017-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102498363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ02254Medicare UPIN
FLQ02254Medicare UPIN