Provider Demographics
NPI:1821182478
Name:THOMPSON, MARY C (CNP, CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:CNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 WEST GENESEE ST.
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031
Mailing Address - Country:US
Mailing Address - Phone:315-488-1112
Mailing Address - Fax:315-488-6707
Practice Address - Street 1:5700 WEST GENESEE ST.
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031
Practice Address - Country:US
Practice Address - Phone:315-488-1112
Practice Address - Fax:315-488-6707
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF0001911367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01935244Medicaid
NYF0001911OtherLICENSE
NYMM0938499OtherDEA
NYF0001911OtherLICENSE
P11430Medicare UPIN