Provider Demographics
NPI:1518282185
Name:THACKERVILLE MEDICAL CLINIC
Entity Type:Organization
Organization Name:THACKERVILLE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:SPROTT
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:940-366-0180
Mailing Address - Street 1:11530 RIDGE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:THACKERVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:73459-9771
Mailing Address - Country:US
Mailing Address - Phone:580-276-9066
Mailing Address - Fax:580-276-9063
Practice Address - Street 1:11530 RIDGE RD STE 1
Practice Address - Street 2:
Practice Address - City:THACKERVILLE
Practice Address - State:OK
Practice Address - Zip Code:73459-9771
Practice Address - Country:US
Practice Address - Phone:580-276-9066
Practice Address - Fax:580-276-9063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-07
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0096598363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80F834Medicare PIN
TX8B6412Medicare PIN
TX8J2882Medicare PIN