Provider Demographics
NPI:1801821889
Name:THOMPSON, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MIKADO DR W
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-1345
Mailing Address - Country:US
Mailing Address - Phone:719-531-5330
Mailing Address - Fax:
Practice Address - Street 1:10TH MEDICAL GROUP
Practice Address - Street 2:4102 PINION DRIVE
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840
Practice Address - Country:US
Practice Address - Phone:719-333-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS34131Medicare UPIN
COJ50063Medicare ID - Type Unspecified