Healthcare Provider Details

I. General information

NPI: 1558364422
Provider Name (Legal Business Name): MICHAEL A THAYER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 N PORTLAND AVE
OKLAHOMA CITY OK
73112-2074
US

IV. Provider business mailing address

4500 S GARNETT RD SUITE 300
TULSA OK
74146-5229
US

V. Phone/Fax

Practice location:
  • Phone: 405-604-6000
  • Fax: 918-664-2521
Mailing address:
  • Phone: 918-664-9892
  • Fax: 918-664-2521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1064
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: