Basic Information
Provider Information | |||||||||
NPI: | 1124317987 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOMSON | ||||||||
FirstName: | LOC | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 64916 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212644916 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4434816481 | ||||||||
FaxNumber: | 4434816515 | ||||||||
Practice Location | |||||||||
Address1: | 2001 MEDICAL PKWY | ||||||||
Address2: | ACUTE CARE PAVILION | ||||||||
City: | ANNAPOLIS | ||||||||
State: | MD | ||||||||
PostalCode: | 214013280 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4434811000 | ||||||||
FaxNumber: | 4102661642 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2011 | ||||||||
LastUpdateDate: | 07/29/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | R151186 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
ID | Type | State | Issuer | Description | 607156012 | 01 |   | US DEPARTMENT OF LABOR | OTHER | 9830738 | 01 |   | AETNA PPO | OTHER | V8140013 | 01 |   | CAREFIRST | OTHER | 8029100 | 01 |   | AETNA HMO | OTHER | 335514400 | 05 | MD |   | MEDICAID | 97430801 | 01 | MD | CAREFIRST | OTHER |