Provider Demographics
NPI:1649739392
Name:THOMPSON, BLAKE TAYLOR (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:TAYLOR
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 FILLMORE ST STE 600
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3343
Mailing Address - Country:US
Mailing Address - Phone:208-933-4400
Mailing Address - Fax:208-933-4401
Practice Address - Street 1:1411 FILLMORE ST STE 600
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3343
Practice Address - Country:US
Practice Address - Phone:208-933-4400
Practice Address - Fax:208-933-4401
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID69119363LF0000X
ID33331146N00000X
ID50167163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No163W00000XNursing Service ProvidersRegistered Nurse