Provider Demographics
NPI:1710022835
Name:THOMPSON, MYRA L (FNP)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38505 BROOTEN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PACIFIC CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97135
Mailing Address - Country:US
Mailing Address - Phone:541-994-6523
Mailing Address - Fax:
Practice Address - Street 1:38505 BROOTEN RD
Practice Address - Street 2:SUITE A
Practice Address - City:PACIFIC CITY
Practice Address - State:OR
Practice Address - Zip Code:97135
Practice Address - Country:US
Practice Address - Phone:541-994-6523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR083030466N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR129788Medicaid
ORR32376Medicare UPIN
OR129788Medicaid