Basic Information
| Provider Information | |||||||||
| NPI: | 1114156171 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | LESLIE | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17095 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923450000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602416666 | ||||||||
| FaxNumber: | 7602417575 | ||||||||
| Practice Location | |||||||||
| Address1: | 12550 HESPERIA ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923950000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602416666 | ||||||||
| FaxNumber: | 7602417575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2009 | ||||||||
| LastUpdateDate: | 10/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA19605 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.