Provider Demographics
NPI:1639542418
Name:THOMPSON, NATHAN (NP)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 S STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-3637
Mailing Address - Country:US
Mailing Address - Phone:906-774-1313
Mailing Address - Fax:
Practice Address - Street 1:500 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:MI
Practice Address - Zip Code:49870-1238
Practice Address - Country:US
Practice Address - Phone:906-563-9255
Practice Address - Fax:906-563-9706
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704281247363L00000X
WI6690-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner