Provider Demographics
NPI:1639640782
Name:THOMPSON, CORT DARCY (PA)
Entity Type:Individual
Prefix:
First Name:CORT
Middle Name:DARCY
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2553
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93447-2553
Mailing Address - Country:US
Mailing Address - Phone:805-674-7411
Mailing Address - Fax:
Practice Address - Street 1:921 OAK PARK BLVD STE 202
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3400
Practice Address - Country:US
Practice Address - Phone:805-473-7818
Practice Address - Fax:805-473-7820
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant