Provider Demographics
NPI:1649739392
Name:THOMPSON, BLAKE TAYLOR (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:TAYLOR
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 E PARK BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-7763
Practice Address - Country:US
Practice Address - Phone:208-381-4210
Practice Address - Fax:208-381-2045
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID33331146N00000X
ID69119363LF0000X
ID50167163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No163W00000XNursing Service ProvidersRegistered Nurse