Healthcare Provider Details

I. General information

NPI: 1548626377
Provider Name (Legal Business Name): DEREK THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2016
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3419 22ND ST
LUBBOCK TX
79410
US

IV. Provider business mailing address

3419 22ND ST
LUBBOCK TX
79410-1334
US

V. Phone/Fax

Practice location:
  • Phone: 806-796-3000
  • Fax: 806-796-3006
Mailing address:
  • Phone: 806-796-3000
  • Fax: 806-796-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP129931
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: