Provider Demographics
NPI:1972112100
Name:THOMPSON, BRE'ANDRIA KAMILLE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRE'ANDRIA
Middle Name:KAMILLE
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 1:1201 GEORGIAN PARK
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-6972
Mailing Address - Country:US
Mailing Address - Phone:770-631-4873
Mailing Address - Fax:
Practice Address - Street 1:1201 GEORGIAN PARK
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-6972
Practice Address - Country:US
Practice Address - Phone:770-631-4873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
GA11339363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program