Healthcare Provider Details

I. General information

NPI: 1427389097
Provider Name (Legal Business Name): ELIZABETH THOMPSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 N MONTE VISTA ST
ADA OK
74820-7711
US

IV. Provider business mailing address

527 W 3RD ST
KONAWA OK
74849-1415
US

V. Phone/Fax

Practice location:
  • Phone: 580-332-8855
  • Fax: 580-332-7374
Mailing address:
  • Phone: 580-925-3286
  • Fax: 580-925-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberP-T0921
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2171
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2172
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerOK BOARD OF MEDICAL LICENSURE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: