1205612496 NPI number — MR. TRISTAN SHARROD THOMPSON MPH

Table of content: MR. TRISTAN SHARROD THOMPSON MPH (NPI 1205612496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205612496 NPI number — MR. TRISTAN SHARROD THOMPSON MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
TRISTAN
Provider Middle Name:
SHARROD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MPH
Provider Gender Code:
M

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:
1205612496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6009 WEST PARKER RD STE 149
Provider Second Line Business Mailing Address:
PMB 238
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
282-884-2975
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6009 W PARKER RD STE 149-238
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-8120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-884-2975
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2023

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: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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