1386670545 NPI number — DR. BRYCE J THACKER DNP, CNS, FNP-C

Table of content: DR. BRYCE J THACKER DNP, CNS, FNP-C (NPI 1386670545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386670545 NPI number — DR. BRYCE J THACKER DNP, CNS, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THACKER
Provider First Name:
BRYCE
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DNP, CNS, FNP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386670545
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
393 ELDRIDGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80807-1356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-343-5388
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 N 6TH ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEYENNE WELLS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80810-5125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-767-5669
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APN.00005929-NP , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 47068731777 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47068731708 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 71638741 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1495796 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0495796 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".