Healthcare Provider Details

I. General information

NPI: 1134148513
Provider Name (Legal Business Name): COREY L THOMPSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 E INDIAN SCHOOL RD STE 21-562
PHOENIX AZ
85018-5360
US

IV. Provider business mailing address

4340 E INDIAN SCHOOL RD STE 21-562
PHOENIX AZ
85018-5360
US

V. Phone/Fax

Practice location:
  • Phone: 480-545-2610
  • Fax: 480-545-2673
Mailing address:
  • Phone: 480-545-2610
  • Fax: 480-545-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberAZ 2069
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: