Provider Demographics
NPI:1902917966
Name:THOMPSON, JEFFREY L (PA-C)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3456 E 17TH ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6757
Mailing Address - Country:US
Mailing Address - Phone:208-529-2828
Mailing Address - Fax:208-529-3890
Practice Address - Street 1:3456 E 17TH ST
Practice Address - Street 2:SUITE 125
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6757
Practice Address - Country:US
Practice Address - Phone:208-529-2828
Practice Address - Fax:208-529-3890
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805638700Medicaid
IDP62293Medicare UPIN
ID1667398Medicare ID - Type Unspecified