Provider Demographics
NPI:1427131721
Name:EGGLESTON THOMPSON, MARY HELEN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:HELEN
Last Name:EGGLESTON THOMPSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:HELEN
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR STE 175
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4401
Mailing Address - Country:US
Mailing Address - Phone:208-625-6309
Mailing Address - Fax:208-625-6310
Practice Address - Street 1:700 W IRONWOOD DR STE 175
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4401
Practice Address - Country:US
Practice Address - Phone:208-625-6300
Practice Address - Fax:208-625-6301
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-564363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000010152059OtherREGENCE BLUESHIELD
IDPAZB8OtherBLUE CROSS OF IDAHO
ID807286200Medicaid
P95645Medicare UPIN
ID807286200Medicaid