MEDICARE: KELLY D THOMPSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0110004519	VA

General Provider Information

NPI Number	:	1700201829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY D THOMPSON PA-C

Provider Business Mailing Address
First Line	:	2296 OPITZ BLVD STE 230
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22191-3345
Country	:	US
Telephone Number	:	703-878-0924
Fax Number	:	703-878-1037

Provider Business Practice Location Address
First Line	:	2296 OPITZ BLVD STE 230
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22191-3345
Country	:	US
Telephone Number	:	703-878-0924
Fax Number	:	703-878-1037

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2014
Last Update Date	:	11/14/2019

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