Basic Information
| Provider Information | |||||||||
| NPI: | 1811212392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | GENA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 E. THIRD STREET | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237785630 | ||||||||
| FaxNumber: | 4237783146 | ||||||||
| Practice Location | |||||||||
| Address1: | 979 E. THIRD STREET | ||||||||
| Address2: | SUITE #C-825 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237784830 | ||||||||
| FaxNumber: | 4237786154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2010 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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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 | 363A00000X | 5745 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2044 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.