Healthcare Provider Details

I. General information

NPI: 1629004619
Provider Name (Legal Business Name): KATHLEEN J. THOMPSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 MAIN ST
SWEET HOME OR
97386-1515
US

IV. Provider business mailing address

PO BOX 579
CORVALLIS OR
97339-0579
US

V. Phone/Fax

Practice location:
  • Phone: 833-990-6300
  • Fax: 541-766-6833
Mailing address:
  • Phone: 541-766-6835
  • Fax: 541-766-6164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00742
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: