Provider Demographics
NPI:1538244702
Name:THOMPSON, JOAN (PA-C)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:
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 1:30 N 1900 E
Mailing Address - Street 2:RM 4B320 SOM
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-2405
Mailing Address - Country:US
Mailing Address - Phone:801-851-6390
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E
Practice Address - Street 2:RM 4B320 SOM
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-2405
Practice Address - Country:US
Practice Address - Phone:801-851-6390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003841363AM0700X
UT7524958-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01285029Medicaid
NYS56058Medicare UPIN
NYDD0492Medicare PIN