Provider Demographics
NPI:1447883897
Name:THOMPSON, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 COURT ST
Mailing Address - Street 2:
Mailing Address - City:JESSUP
Mailing Address - State:PA
Mailing Address - Zip Code:18434-1614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:804 COURT ST
Practice Address - Street 2:
Practice Address - City:JESSUP
Practice Address - State:PA
Practice Address - Zip Code:18434-1614
Practice Address - Country:US
Practice Address - Phone:570-604-6997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant