Provider Demographics
NPI:1457024424
Name:THAYER, ERIC DUANE (DNP)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DUANE
Last Name:THAYER
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5424 GLENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-1332
Mailing Address - Country:US
Mailing Address - Phone:651-276-2700
Mailing Address - Fax:
Practice Address - Street 1:5424 GLENWOOD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-1332
Practice Address - Country:US
Practice Address - Phone:651-276-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA164805207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA164805OtherIOWA BOARD OF NURSING ARNP LICENSE