Basic Information
| Provider Information | |||||||||
| NPI: | 1871562835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOX THOMPSON | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80217 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850600217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023852115 | ||||||||
| FaxNumber: | 4804183323 | ||||||||
| Practice Location | |||||||||
| Address1: | 2940 E BANNER GATEWAY DR STE 200-250 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852342168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026485444 | ||||||||
| FaxNumber: | 6027723801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9106053 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3353 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 106823400 | 05 | FL | MEDICAID | Y0AW1 | 01 | FL | BCBSFL | OTHER | FV664X | 01 | FL | MEDICARE | OTHER |