Healthcare Provider Details

I. General information

NPI: 1770536963
Provider Name (Legal Business Name): THURSTON MEDICAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S 15TH ST
WORLAND WY
82401-3530
US

IV. Provider business mailing address

401 S 15TH ST
WORLAND WY
82401-3530
US

V. Phone/Fax

Practice location:
  • Phone: 307-347-2525
  • Fax: 307-347-3949
Mailing address:
  • Phone: 307-347-2525
  • Fax: 307-347-3949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5442A
License Number StateWY

VIII. Authorized Official

Name: JOHN E THURSTON
Title or Position: PRESIDENT
Credential: MD
Phone: 307-347-2525