Provider Demographics
NPI:1972122430
Name:THOMPSON, TAYLOR AUSTIN
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:AUSTIN
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:CMR 402 BOX 746
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-0008
Mailing Address - Country:US
Mailing Address - Phone:989-751-5523
Mailing Address - Fax:
Practice Address - Street 1:86TH MEDICAL GROUP
Practice Address - Street 2:UNIT 3215
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09094
Practice Address - Country:US
Practice Address - Phone:314-479-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians