1578907630 NPI number — MS. CHASARETH EDWONNE THOMPSON PA-C

Table of content: MS. CHASARETH EDWONNE THOMPSON PA-C (NPI 1578907630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578907630 NPI number — MS. CHASARETH EDWONNE THOMPSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
CHASARETH
Provider Middle Name:
EDWONNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578907630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 UNIVERSITY DR E
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77840-2600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-846-1100
Provider Business Mailing Address Fax Number:
979-260-9390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 DOVE CROSSING LN
Provider Second Line Business Practice Location Address:
SUITE #C
Provider Business Practice Location Address City Name:
NAVASOTA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77868-5272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-825-0000
Provider Business Practice Location Address Fax Number:
979-825-8001
Provider Enumeration Date:
04/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA08203 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 45-1981 . This is a "MEDICARE/GRIMES COUNTY CHC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 74-1715140 . This is a "BRAZOS VALLEY COMMUNITY ACTION AGENCY, INC." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1821185299 . This is a "BRAZOS VALLEY COMMUNITY ACTION AGENCY, INC." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0009516-07 . This is a "MEDICAID/GRIMES COUNTY CHC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1700973187 . This is a "NPI/GRIMES COUNTY CHC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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