Healthcare Provider Details

I. General information

NPI: 1275371049
Provider Name (Legal Business Name): GERVON R THOMPSON PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 07/17/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 E 121ST ST # 5
NEW YORK NY
10035-3523
US

IV. Provider business mailing address

1977 RALPH AVE STE B
BROOKLYN NY
11234-5416
US

V. Phone/Fax

Practice location:
  • Phone: 212-801-3300
  • Fax:
Mailing address:
  • Phone: 718-444-0092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF406088-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: