Provider Demographics
NPI:1740361997
Name:THOMPSON, SALLY ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ELIZABETH
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:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-273-8740
Mailing Address - Fax:352-392-0821
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:M452
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-8740
Practice Address - Fax:352-392-0821
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103789363A00000X
FLPA9103789363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000848900Medicaid
FL000848900Medicaid
FLBN533YMedicare PIN