Healthcare Provider Details

I. General information

NPI: 1932896081
Provider Name (Legal Business Name): THANE SWISSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 HIGHWAY 25 N
BUFFALO MN
55313-1930
US

IV. Provider business mailing address

1700 HIGHWAY 25 N
BUFFALO MN
55313-1930
US

V. Phone/Fax

Practice location:
  • Phone: 763-682-1313
  • Fax: 763-581-9090
Mailing address:
  • Phone: 763-682-1313
  • Fax: 763-581-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number77768
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: