Basic Information
| Provider Information | |||||||||
| NPI: | 1740954668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | COY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3465 MCNUTT RD | ||||||||
| Address2: | |||||||||
| City: | SUNLAND PARK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880639056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5759151338 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2801 MISSOURI AVE STE 22 | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880115062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5759151338 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2021 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.