Provider Demographics
NPI:1295703593
Name:THOMPSON, TRICIA
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2818
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2818
Mailing Address - Country:US
Mailing Address - Phone:319-233-3044
Mailing Address - Fax:319-233-0722
Practice Address - Street 1:3741 PHEASANT LN
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-5215
Practice Address - Country:US
Practice Address - Phone:319-233-3611
Practice Address - Fax:319-233-0669
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA099677363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAQ07207Medicare UPIN
IAQ07207Medicare UPIN
IA30947OtherBCBS
IAI19431Medicare ID - Type Unspecified