1508162645 NPI number — MRS. SARA NICOLE THOMPSON PA-C

Table of content: MRS. SARA NICOLE THOMPSON PA-C (NPI 1508162645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508162645 NPI number — MRS. SARA NICOLE THOMPSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
SARA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
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:
NILIUS
Provider Other First Name:
SARA
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1508162645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 S FISKE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955-4306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-308-2660
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1421 MALABAR RD NE STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM BAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32907-2559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-308-2660
Provider Business Practice Location Address Fax Number:
321-984-9303
Provider Enumeration Date:
02/08/2011

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: 363A00000X , with the licence number:  PA9108278 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PENDING , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: PA9108278 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: MEDICARE . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: KQ667 . This is a "FL MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 101749800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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