Healthcare Provider Details

I. General information

NPI: 1932195963
Provider Name (Legal Business Name): MICHAEL GLASS THOMPSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 HIGHWAY 192 W
LONDON KY
40741-2428
US

IV. Provider business mailing address

189 WEST HWY 192 BYPASS SUITE 2
LONDON KY
40741
US

V. Phone/Fax

Practice location:
  • Phone: 859-252-6500
  • Fax: 606-877-5454
Mailing address:
  • Phone: 859-252-6500
  • Fax: 606-877-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA796
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: