Basic Information
Provider Information | |||||||||
NPI: | 1922143445 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOMPSON | ||||||||
FirstName: | NICOLETTE | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 190 | ||||||||
Address2: |   | ||||||||
City: | TOPPENISH | ||||||||
State: | WA | ||||||||
PostalCode: | 989480190 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415671717 | ||||||||
FaxNumber: | 5415679662 | ||||||||
Practice Location | |||||||||
Address1: | 589 NW 11TH STREET | ||||||||
Address2: |   | ||||||||
City: | HERMISTON | ||||||||
State: | OR | ||||||||
PostalCode: | 978386600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415671717 | ||||||||
FaxNumber: | 5415679662 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2007 | ||||||||
LastUpdateDate: | 09/20/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00656 | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | MS1244273 | 01 |   | DEA | OTHER |