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NPI Code Detail

MEDICARE: MARYBETH THORN PA-C

MEDICARE: MARYBETH THORN PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant244CO
2363AM0700XMedical Physician Assistant102676NC
3363A00000XPhysician Assistant86-PA052NM

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2PA244OTHERCOCOLORADO LICENSE
3102676OTHERNCNC LICENSE

General Provider Information

NPI Number : 1730253063
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARYBETH THORN PA-C
Provider Business Mailing Address
First Line : 5904 HOLLY AVE NE
Second Line :
City : ALBUQUERQUE
State : NM
Zip : 87113-2472
Country : US
Telephone Number : 505-298-2505
Fax Number : 505-298-2505
Provider Business Practice Location Address
First Line : 5904 HOLLY AVE NE
Second Line :
City : ALBUQUERQUE
State : NM
Zip : 87113-2472
Country : US
Telephone Number : 505-298-2505
Fax Number : 505-298-2985
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/20/2006
Last Update Date : 04/07/2021

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Directions to “ MARYBETH THORN PA-C” Practice Location

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