Healthcare Provider Details

I. General information

NPI: 1538244702
Provider Name (Legal Business Name): JOAN THOMPSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E RM 4B320 SOM
SALT LAKE CITY UT
84132-2405
US

IV. Provider business mailing address

30 N 1900 E RM 4B320 SOM
SALT LAKE CITY UT
84132-2405
US

V. Phone/Fax

Practice location:
  • Phone: 801-851-6390
  • Fax:
Mailing address:
  • Phone: 801-851-6390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7524958-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003841
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: