Healthcare Provider Details

I. General information

NPI: 1134877939
Provider Name (Legal Business Name): DEANDRA MARISSAH THOMPSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 NW 11TH ST
FAIRFIELD IL
62837-1206
US

IV. Provider business mailing address

613 W 12TH ST
FLORA IL
62839-1066
US

V. Phone/Fax

Practice location:
  • Phone: 618-842-2611
  • Fax:
Mailing address:
  • Phone: 618-508-3459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: