Basic Information
| Provider Information | |||||||||
| NPI: | 1063863876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 441 S REDWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841043539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019732588 | ||||||||
| FaxNumber: | 8019736985 | ||||||||
| Practice Location | |||||||||
| Address1: | 441 S REDWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841043539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019732588 | ||||||||
| FaxNumber: | 8019736985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2016 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 8021622-8900 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.