Provider Demographics
NPI:1043544125
Name:THOMPSON, RYAN BRADFORD (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:BRADFORD
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17197 N. LAUREL PARK DRIVE
Mailing Address - Street 2:SUITE 161
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152
Mailing Address - Country:US
Mailing Address - Phone:734-338-8300
Mailing Address - Fax:734-338-8301
Practice Address - Street 1:7733 EAST JEFFERSON
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213
Practice Address - Country:US
Practice Address - Phone:313-499-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005559363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical