Provider Demographics
NPI:1982121059
Name:MIRELES THORN, SALVADOR (PA-C)
Entity Type:Individual
Prefix:
First Name:SALVADOR
Middle Name:
Last Name:MIRELES THORN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:SALVADOR
Other - Middle Name:MIRELES
Other - Last Name:THORN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:350 LEGACY LAKES WAY
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:NC
Mailing Address - Zip Code:28315-4994
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BYARS CLINIC
Practice Address - Street 2:2864 WOODRUFF STREET
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28302
Practice Address - Country:US
Practice Address - Phone:910-907-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11074363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant