Provider Demographics
NPI:1811126923
Name:THOMPSON, DERIK (CSA)
Entity type:Individual
Prefix:
First Name:DERIK
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 LYNNHAVEN PKWY STE 106-308
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-1497
Mailing Address - Country:US
Mailing Address - Phone:757-573-3479
Mailing Address - Fax:
Practice Address - Street 1:2085 LYNNHAVEN PKWY STE 106-308
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-1497
Practice Address - Country:US
Practice Address - Phone:757-573-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000166363AS0400X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty