Basic Information
| Provider Information | |||||||||
| NPI: | 1457432833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THORN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 3305 ROUTE 43 | ||||||||
| Address2: | |||||||||
| City: | AVERILL PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186745797 | ||||||||
| FaxNumber: | 5186742396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 01/18/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 187244 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10002042 | 01 | NY | CDPHP | OTHER | 5731176 | 01 | NY | AETNA | OTHER | 01397479 | 05 | NY | MEDICAID | 92949 | 01 | NY | GHI/HMO | OTHER | 5562A1 | 01 | NY | EMPIRE BC | OTHER | FIDELIS | 01 | NY | 070129000060 | OTHER | 000401537006 | 01 | NY | BSNENY | OTHER | 383845 | 01 | NY | MVP | OTHER | SENIOR WHOLE HEALTH | 01 | NY | 200249 | OTHER |