Provider Demographics
NPI:1629053764
Name:THAYER, LUANN MARY (NP)
Entity Type:Individual
Prefix:
First Name:LUANN
Middle Name:MARY
Last Name:THAYER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 GENESEE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2658
Mailing Address - Country:US
Mailing Address - Phone:315-363-8862
Mailing Address - Fax:315-363-3326
Practice Address - Street 1:357 GENESEE ST STE 1
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2658
Practice Address - Country:US
Practice Address - Phone:315-363-8862
Practice Address - Fax:315-363-3326
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332301-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02509048Medicaid
P24316Medicare UPIN
NYRA4613Medicare PIN
NYJ400187226Medicare UPIN