Healthcare Provider Details

I. General information

NPI: 1285773671
Provider Name (Legal Business Name): BRIAN D THWAITES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 CONGRESS ST
SHERIDAN MI
48884-9215
US

IV. Provider business mailing address

301 N MAIN ST P.O BOX 155
SHERIDAN MI
48884-9235
US

V. Phone/Fax

Practice location:
  • Phone: 989-291-5077
  • Fax: 989-291-4348
Mailing address:
  • Phone: 989-291-6264
  • Fax: 989-291-5350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003377
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: