Provider Demographics
NPI:1174122121
Name:THOMPSON, JOHN MYCHAL (MSN, APRN, AGNP-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MYCHAL
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MSN, APRN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 TERRACE
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2040
Mailing Address - Country:US
Mailing Address - Phone:870-833-1060
Mailing Address - Fax:
Practice Address - Street 1:3002 MOORES LN
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2204
Practice Address - Country:US
Practice Address - Phone:430-200-4350
Practice Address - Fax:833-491-2722
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR212494363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology