Provider Demographics
NPI:1952774093
Name:THAYER, LISA (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:THAYER
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155R GUILFORD RD
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06422-2815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:860-661-6574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6214363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner