Healthcare Provider Details

I. General information

NPI: 1629018916
Provider Name (Legal Business Name): GARY C THOMPSON PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BRIDGE ST STE 300
DANVILLE VA
24541-1222
US

IV. Provider business mailing address

1772 BLAIR LOOP RD
DANVILLE VA
24541-5013
US

V. Phone/Fax

Practice location:
  • Phone: 434-793-4711
  • Fax: 434-797-2514
Mailing address:
  • Phone: 434-822-0339
  • Fax: 434-797-2514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110000067
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: