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General NPI Number Information
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NPI Number | 1811126923
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Entity Type | Individual
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Provider Name | DERIK THOMPSON CSA
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Gender | Male
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Dates
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Enumeration Date | 07/09/2009
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Last Update Date | 12/19/2019
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Provider Practice Location Address
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Address Line | 2085 LYNNHAVEN PKWY STE 106-308
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City | VIRGINIA BEACH
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State | VA
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Zip | 23456-1497
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Country | US
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Telephone | 757-573-3479
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Fax |
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Provider Business Mailing Address
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Address Line | 2085 LYNNHAVEN PKWY STE 106-308
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City | VIRGINIA BEACH
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State | VA
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Zip | 23456-1497
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Country | US
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Telephone | 757-573-3479
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 0136000166
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License Number State | VA
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