Provider Demographics
NPI:1003484411
Name:PARKER, THAYNE MADSEN (DO)
Entity Type:Individual
Prefix:
First Name:THAYNE
Middle Name:MADSEN
Last Name:PARKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4090 BLACKBERRY LN
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-1764
Mailing Address - Country:US
Mailing Address - Phone:702-338-5545
Mailing Address - Fax:
Practice Address - Street 1:5515 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2603
Practice Address - Country:US
Practice Address - Phone:702-338-5545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-12
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT020988390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program