Provider Demographics
NPI:1447966775
Name:THOMPSON, JOHN SIRDRE (STUDENT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SIRDRE
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 EDNAM DR # 104
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-4629
Mailing Address - Country:US
Mailing Address - Phone:910-691-1559
Mailing Address - Fax:
Practice Address - Street 1:141 EDNAM DR # 104
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4629
Practice Address - Country:US
Practice Address - Phone:910-691-1559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
390200000XOtherSTUDENT