Healthcare Provider Details

I. General information

NPI: 1407616303
Provider Name (Legal Business Name): TRACY L THOMPSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 E CHURCH ST STE B
BENTON IL
62812-2239
US

IV. Provider business mailing address

PO BOX 155
CHRISTOPHER IL
62822-0155
US

V. Phone/Fax

Practice location:
  • Phone: 618-435-9888
  • Fax:
Mailing address:
  • Phone: 618-724-2401
  • Fax: 618-724-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085010786
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: