1508985144 NPI number — KIMBERLY LEA THOMPSON-TUCKER PA-C

Table of content: KIMBERLY LEA THOMPSON-TUCKER PA-C (NPI 1508985144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508985144 NPI number — KIMBERLY LEA THOMPSON-TUCKER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON-TUCKER
Provider First Name:
KIMBERLY
Provider Middle Name:
LEA
Provider Name Prefix Text:
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:
THOMPSON
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508985144
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1412 CAROLINA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27889-3314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-623-2000
Provider Business Mailing Address Fax Number:
877-559-4667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1412 CAROLINA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27889-3314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-623-2000
Provider Business Practice Location Address Fax Number:
877-559-4667
Provider Enumeration Date:
03/28/2007

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:  102890 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102890 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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