Individual
MARYBETH THORN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
5904 HOLLY AVE NE, ALBUQUERQUE, NM 87113-2472
(505) 298-2505
(505) 298-2985
Mailing address
5904 HOLLY AVE NE, ALBUQUERQUE, NM 87113-2472
(505) 298-2505
(505) 298-2505
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
244
CO
363A00000X
Physician Assistant
Primary
86-PA052
NM
363AM0700X
Medical Physician Assistant
102676
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
102676
NC LICENSE
NC
05
—
91407770
—
CO
01
—
PA244
COLORADO LICENSE
CO
Enumeration date
11/20/2006
Last updated
04/07/2021
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