Provider Demographics
NPI:1134877939
Name:THOMPSON, DEANDRA MARISSAH (PA)
Entity type:Individual
Prefix:
First Name:DEANDRA
Middle Name:MARISSAH
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-1066
Mailing Address - Country:US
Mailing Address - Phone:618-508-3459
Mailing Address - Fax:
Practice Address - Street 1:303 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-1206
Practice Address - Country:US
Practice Address - Phone:618-842-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant