Healthcare Provider Details

I. General information

NPI: 1821896804
Provider Name (Legal Business Name): INTEGRATIVE DERMATOLOGY PA CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 03/07/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 ECHO PASS ST.
HENDERSON NV
89052
US

IV. Provider business mailing address

7533 S CENTER VIEW CT STE R
WEST JORDAN UT
84084-5526
US

V. Phone/Fax

Practice location:
  • Phone: 941-840-1387
  • Fax:
Mailing address:
  • Phone: 941-840-1387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FEROZA THOMPSON
Title or Position: PHYSICIAN ASSOCIATE
Credential: PA-C
Phone: 941-840-1387