Basic Information
| Provider Information | |||||||||
| NPI: | 1760563399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | SUMMER | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORENO | ||||||||
| OtherFirstName: | SUMMER | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 6235375601 | ||||||||
| Practice Location | |||||||||
| Address1: | 18444 N 25TH AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 10/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3514 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 3514 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 3514 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 5550830003 | 01 | AZ | MEDICARE NSC PEORIA | OTHER | 5550830010 | 01 | AZ | MEDICARE NSC GILBERT | OTHER | 5550830009 | 01 | AZ | MEDICARE NSC AZ NORTH | OTHER | 5550830001 | 01 | AZ | MEDICARE NSC SCW | OTHER | 5550830008 | 01 | AZ | MEDICARE NSC SWV | OTHER | 5550830004 | 01 | AZ | MEDICARE NSC PV | OTHER | 143978 | 05 | AZ | MEDICAID | 5550830006 | 01 | AZ | MEDICARE NSC ANTHEM | OTHER | 5550830007 | 01 | AZ | MEDICARE NSC DV | OTHER |