Provider Demographics
NPI:1831287895
Name:THORN, DALE LEROY (PA)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:LEROY
Last Name:THORN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4623
Mailing Address - Country:US
Mailing Address - Phone:907-269-7167
Mailing Address - Fax:907-269-7251
Practice Address - Street 1:2800 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4623
Practice Address - Country:US
Practice Address - Phone:907-269-7167
Practice Address - Fax:907-269-7251
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK283363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical