Provider Demographics
NPI:1114756962
Name:THOMPSON, JUSTIN PAUL
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:PAUL
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 EGRET CIR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4354
Mailing Address - Country:US
Mailing Address - Phone:706-306-0422
Mailing Address - Fax:
Practice Address - Street 1:2028 EGRET CIR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-4354
Practice Address - Country:US
Practice Address - Phone:706-306-0422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN238780163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse