Healthcare Provider Details

I. General information

NPI: 1528892247
Provider Name (Legal Business Name): DEVON THOMPSON PA-C
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/27/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1178 5TH ST SE
CAIRO GA
39828-3141
US

IV. Provider business mailing address

1178 5TH ST SE
CAIRO GA
39828-3141
US

V. Phone/Fax

Practice location:
  • Phone: 229-377-2002
  • Fax:
Mailing address:
  • Phone: 229-377-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12542
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: