Provider Demographics
NPI:1528611191
Name:PETERSEN-THOMPSON, KATHRYN (DO)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:PETERSEN-THOMPSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:430 RISEN STAR DR
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29316-8004
Mailing Address - Country:US
Mailing Address - Phone:435-592-9631
Mailing Address - Fax:
Practice Address - Street 1:853 N CHURCH ST STE 510
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3077
Practice Address - Country:US
Practice Address - Phone:864-560-6193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL82955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine