Healthcare Provider Details

I. General information

NPI: 1053700013
Provider Name (Legal Business Name): TREVOR THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 HOSPITAL LOOP NE
ALBUQUERQUE NM
87109-2115
US

IV. Provider business mailing address

103 HOSPITAL LOOP NE
ALBUQUERQUE NM
87109-2115
US

V. Phone/Fax

Practice location:
  • Phone: 505-348-8300
  • Fax:
Mailing address:
  • Phone: 505-348-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0970
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: