Provider Demographics
NPI:1992848352
Name:THURSTON, MIRA-SU (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MIRA-SU
Middle Name:
Last Name:THURSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MADELYN LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4460
Mailing Address - Country:US
Mailing Address - Phone:207-593-5900
Mailing Address - Fax:207-593-5358
Practice Address - Street 1:7 MADELYN LN
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4460
Practice Address - Country:US
Practice Address - Phone:207-593-5900
Practice Address - Fax:207-593-5358
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA637363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical