Provider Demographics
NPI:1811212392
Name:THOMPSON, GENA L (PA-C)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:F
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 1:975 E. THIRD STREET
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2147
Mailing Address - Country:US
Mailing Address - Phone:423-778-5630
Mailing Address - Fax:423-778-3146
Practice Address - Street 1:979 E. THIRD STREET
Practice Address - Street 2:SUITE #C-825
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403
Practice Address - Country:US
Practice Address - Phone:423-778-4830
Practice Address - Fax:423-778-6154
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5745363A00000X
TN2044363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I976352Medicare PIN