Provider Demographics
NPI:1720219124
Name:THORNTON, TORY MICHAEL (FNP)
Entity Type:Individual
Prefix:
First Name:TORY
Middle Name:MICHAEL
Last Name:THORNTON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:541-523-4465
Mailing Address - Fax:541-524-9032
Practice Address - Street 1:3820 17TH ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814
Practice Address - Country:US
Practice Address - Phone:541-523-4465
Practice Address - Fax:541-524-9032
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200950107NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner