Healthcare Provider Details

I. General information

NPI: 1225339815
Provider Name (Legal Business Name): STEPHANIE M THOMPSON P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MIMOSA DR FL 3
THOMASVILLE GA
31792-6676
US

IV. Provider business mailing address

100 MIMOSA DR FL 3
THOMASVILLE GA
31792-6676
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-8881
  • Fax: 229-584-5964
Mailing address:
  • Phone: 229-226-8881
  • Fax: 229-584-5964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005967
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: