Provider Demographics
NPI:1558364422
Name:THAYER, MICHAEL A (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:THAYER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4500 S GARNETT RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5229
Mailing Address - Country:US
Mailing Address - Phone:918-664-9892
Mailing Address - Fax:918-664-2521
Practice Address - Street 1:5501 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2074
Practice Address - Country:US
Practice Address - Phone:405-604-6000
Practice Address - Fax:918-664-2521
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1064363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100090360AMedicaid
OK100090360AMedicaid
OKOK401841Medicare PIN
OKPA001064Medicare ID - Type Unspecified