Provider Demographics
NPI:1063539856
Name:THOMPSON, MICHAEL SHANE (RAS, CDAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:RAS, CDAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12309 HORSESHOE RD
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-9517
Mailing Address - Country:US
Mailing Address - Phone:209-847-5480
Mailing Address - Fax:
Practice Address - Street 1:500 N 9TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5814
Practice Address - Country:US
Practice Address - Phone:209-541-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator