Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 1477 | ND |
Y | 213ES0000X | Sports Medicine | 1477 | ND |
N | 225100000X | Physical Therapist | 1477 | ND |
NPI | 1467462127 |
---|---|
Provider Name | Mr. Scott Jake Thompson |
First Address | Grand Forks, ND 58202-9013 |
Second Address | Grand Forks, ND 58202-9013 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/08/2006 |
Last Update Date | 30/10/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
45-6002491 | TAX-ID (01) | ND |