Basic Information
| Provider Information | |||||||||
| NPI: | 1780817528 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1535 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984011535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Practice Location | |||||||||
| Address1: | 1304 FAWCETT AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984021911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2009 | ||||||||
| LastUpdateDate: | 01/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA60113828 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0255097 | 01 | WA | LNI-TRA PIERCE COUNTY | OTHER | 0255098 | 01 | WA | LNI-UNION AVE OPEN MRI | OTHER | 0350356 | 01 | WA | LNI-TRA KING COUNTY | OTHER | 0392051 | 01 | WA | LNI-DIAGNOSTIC IMAGING NW | OTHER | 2003472 | 05 | WA | MEDICAID |