Provider Demographics
NPI:1669752119
Name:THOMPSON, WAYNE EDWARD JR
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:EDWARD
Last Name:THOMPSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FARDON ST
Mailing Address - Street 2:
Mailing Address - City:BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01821-3604
Mailing Address - Country:US
Mailing Address - Phone:978-857-0998
Mailing Address - Fax:
Practice Address - Street 1:6 FARDON ST
Practice Address - Street 2:
Practice Address - City:BILLERICA
Practice Address - State:MA
Practice Address - Zip Code:01821-3604
Practice Address - Country:US
Practice Address - Phone:978-857-0998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS29998007390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program