Basic Information
| Provider Information | |||||||||
| NPI: | 1811185333 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | MERVIANNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 ALTO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875012406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059824425 | ||||||||
| FaxNumber: | 5059828440 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 CAMINO SIERRA VIS | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875053018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059881742 | ||||||||
| FaxNumber: | 5057808611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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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 | 363LC1500X | TL02117 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 68971567 | 05 | NM | MEDICAID | TXB106001 | 01 | TX | MEDICARE PTAN | OTHER |