Basic Information
| Provider Information | |||||||||
| NPI: | 1972087658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAREK | ||||||||
| FirstName: | THAIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUGER | ||||||||
| OtherFirstName: | THAIS | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 240 N AUBURN ST | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959456207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053502036 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 155 GLASSON WAY | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959455723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302746000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2018 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95009276 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 95009276 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.