Basic Information
Provider Information | |||||||||
NPI: | 1093942674 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THORN | ||||||||
FirstName: | LINDSAY | ||||||||
MiddleName: | MEGAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CROWELL | ||||||||
OtherFirstName: | LINDSAY | ||||||||
OtherMiddleName: | MEGAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 95004 | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338045004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636807000 | ||||||||
FaxNumber: | 8636807420 | ||||||||
Practice Location | |||||||||
Address1: | 1755 N. FLORIDA AVENUE | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338053109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8639046200 | ||||||||
FaxNumber: | 8639046280 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/22/2009 | ||||||||
LastUpdateDate: | 06/21/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9105041 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X |   | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.