Provider Demographics
NPI:1760563399
Name:THOMPSON, SUMMER NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:NICOLE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SUMMER
Other - Middle Name:NICOLE
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:18444 N 25TH AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1261
Mailing Address - Country:US
Mailing Address - Phone:623-537-5600
Mailing Address - Fax:623-537-5601
Practice Address - Street 1:18444 N 25TH AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-1261
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3514363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5550830010OtherMEDICARE NSC GILBERT
AZ5550830003OtherMEDICARE NSC PEORIA
AZ5550830001OtherMEDICARE NSC SCW
AZ5550830009OtherMEDICARE NSC AZ NORTH
AZ143978Medicaid
AZ5550830007OtherMEDICARE NSC DV
AZ5550830004OtherMEDICARE NSC PV
AZ5550830006OtherMEDICARE NSC ANTHEM
AZ5550830008OtherMEDICARE NSC SWV
AZ5550830007OtherMEDICARE NSC DV
AZ5550830008OtherMEDICARE NSC SWV