Basic Information
| Provider Information | |||||||||
| NPI: | 1427405034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | CLINT | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2690 NE KRESKY AVE | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603309595 | ||||||||
| FaxNumber: | 3603309560 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 CEDAR CREST DR | ||||||||
| Address2: | |||||||||
| City: | WINLOCK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985969791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607859400 | ||||||||
| FaxNumber: | 3607850236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2016 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OP60774572 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2059208 | 05 | WA | MEDICAID |