Provider Demographics
NPI:1619902616
Name:THURMAN, TREVIN (MD)
Entity Type:Individual
Prefix:
First Name:TREVIN
Middle Name:
Last Name:THURMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5530
Mailing Address - Country:US
Mailing Address - Phone:307-745-8851
Mailing Address - Fax:307-742-0961
Practice Address - Street 1:1909 VISTA DR
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5530
Practice Address - Country:US
Practice Address - Phone:307-745-8851
Practice Address - Fax:307-742-0961
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA228665208100000X
PAMD4385912081P2900X
WYTL62672081P2900X
CAA1144702081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102418027Medicaid
PA170689RKKMedicare PIN