Healthcare Provider Details

I. General information

NPI: 1891703633
Provider Name (Legal Business Name): STEPHEN W THOMPSON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 CHAFEE AVE
AUGUSTA GA
30904-5867
US

IV. Provider business mailing address

1120 15TH ST STE BI1056
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2426
  • Fax:
Mailing address:
  • Phone: 706-721-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10000117A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number005595
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: