Provider Demographics
NPI:1841306339
Name:THORNE, GARY MARVIN (MD, FACS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:MARVIN
Last Name:THORNE
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 SWALLOWS NEST LOOP
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1726
Mailing Address - Country:US
Mailing Address - Phone:208-758-0361
Mailing Address - Fax:
Practice Address - Street 1:307 SAINT JOHNS WAY
Practice Address - Street 2:SUITE 5
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2435
Practice Address - Country:US
Practice Address - Phone:208-746-0133
Practice Address - Fax:208-746-0134
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-3996174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001529600Medicaid
ID000010006068OtherREGENCE
ID0083005OtherDLI
ID13DO521109OtherLAB
WA1502103Medicaid
ID91-1074791Medicare UPIN
ID13DO521109OtherLAB
ID0083005OtherDLI
ID000010006068OtherREGENCE
WAAB37301Medicare ID - Type UnspecifiedWASHINGTON MEDICARE