Provider Demographics
NPI:1720069131
Name:THOMSON, DEBRA ANN GRAY (NP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANN GRAY
Last Name:THOMSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4207 FRIEDBERG CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-6875
Mailing Address - Country:US
Mailing Address - Phone:336-764-5444
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:10 BRENNER TOWER
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-713-2255
Practice Address - Fax:336-713-2242
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC130213363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003643Medicaid