Provider Demographics
NPI:1306333422
Name:THOMPSON, WALLACE LEE
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:LEE
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 1:763 PRIEST HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:PA
Mailing Address - Zip Code:16345-4633
Mailing Address - Country:US
Mailing Address - Phone:814-688-1531
Mailing Address - Fax:
Practice Address - Street 1:100 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1868
Practice Address - Country:US
Practice Address - Phone:814-688-1531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-14
Last Update Date:2018-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE1003187225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant