Provider Demographics
NPI:1265823074
Name:THANAVARO, THEERARAT
Entity Type:Individual
Prefix:
First Name:THEERARAT
Middle Name:
Last Name:THANAVARO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 MATTS WAY
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:MO
Mailing Address - Zip Code:63341-2524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9512 HARFORD RD
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-3100
Practice Address - Country:US
Practice Address - Phone:410-665-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-16
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014015283363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health