Provider Demographics
NPI:1548595259
Name:THAKURI, PRABIN (AA)
Entity Type:Individual
Prefix:
First Name:PRABIN
Middle Name:
Last Name:THAKURI
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8739 NW 38TH ST APT 228
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-1502
Mailing Address - Country:US
Mailing Address - Phone:612-270-9975
Mailing Address - Fax:
Practice Address - Street 1:410 S 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4203
Practice Address - Country:US
Practice Address - Phone:863-676-1433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA46367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAA46OtherLICENSE