Provider Demographics
NPI:1891703633
Name:THOMPSON, STEPHEN W (PA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:W
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 1:1120 15TH ST STE BI1056
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-3813
Mailing Address - Fax:
Practice Address - Street 1:1003 CHAFEE AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5867
Practice Address - Country:US
Practice Address - Phone:706-721-2426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000117A363AS0400X
GA005595363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA156406219AMedicaid
SC0834PAMedicaid
000000108476OtherANTHEM
KY9500118600Medicaid
000000108476OtherANTHEM
R61506Medicare UPIN
IN970004754Medicare ID - Type UnspecifiedIN RR MCR
IN532500XMedicare ID - Type UnspecifiedIN MCR