Healthcare Provider Details

I. General information

NPI: 1528103314
Provider Name (Legal Business Name): HEATHER D THOERNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER D EDWARDS MD

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 UNSER BLVD SE STE 8100
ALBUQUERQUE NM
87124-3392
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-253-6100
  • Fax: 505-253-6186
Mailing address:
  • Phone: 505-253-6100
  • Fax: 505-253-6186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD2023-1355
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number49976
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: