Provider Demographics
NPI:1194198929
Name:THORNE, TODD (PA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:THORNE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6856
Mailing Address - Country:US
Mailing Address - Phone:208-737-6718
Mailing Address - Fax:208-324-9191
Practice Address - Street 1:218 W NEZ PERCE
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338
Practice Address - Country:US
Practice Address - Phone:208-324-3471
Practice Address - Fax:208-324-9191
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1822363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1730135310Medicare Oscar/Certification