Provider Demographics
NPI:1679259535
Name:THOMPSON, TYLER (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
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 1:45 PINE STREET
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEGANY
Mailing Address - State:PA
Mailing Address - Zip Code:16743
Mailing Address - Country:US
Mailing Address - Phone:814-642-9655
Mailing Address - Fax:
Practice Address - Street 1:45 PINE STREET
Practice Address - Street 2:
Practice Address - City:PORT ALLEGANY
Practice Address - State:PA
Practice Address - Zip Code:16743
Practice Address - Country:US
Practice Address - Phone:814-642-9655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA006537363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant