Provider Demographics
NPI:1679682447
Name:THOMPSON, MICHAEL D (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3310
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:918-488-6010
Practice Address - Street 1:6475 S YALE AVE STE 200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7816
Practice Address - Country:US
Practice Address - Phone:918-494-4460
Practice Address - Fax:918-494-4442
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003020147363AS0400X
OK1774363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200020890AMedicaid