Healthcare Provider Details

I. General information

NPI: 1023443975
Provider Name (Legal Business Name): MARC THERRIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 RUSSET LN
SYRACUSE NY
13209-2010
US

IV. Provider business mailing address

102 RUSSET LN
SYRACUSE NY
13209-2010
US

V. Phone/Fax

Practice location:
  • Phone: 315-263-0526
  • Fax:
Mailing address:
  • Phone: 315-263-0526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number568620
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: