Provider Demographics
NPI:1821460072
Name:THOMPSON, TYRELL (ROT)
Entity Type:Individual
Prefix:
First Name:TYRELL
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:ROT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S WANDLING AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07882-2130
Mailing Address - Country:US
Mailing Address - Phone:908-797-4802
Mailing Address - Fax:
Practice Address - Street 1:50 S WANDLING AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07882-2130
Practice Address - Country:US
Practice Address - Phone:908-797-4802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program