Provider Demographics
NPI:1023651643
Name:THAILER, RICHARD (PA-C)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:THAILER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MANSFIELD LN S
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-4134
Mailing Address - Country:US
Mailing Address - Phone:631-334-0627
Mailing Address - Fax:
Practice Address - Street 1:19 MANSFIELD LN S
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-4134
Practice Address - Country:US
Practice Address - Phone:631-334-0627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-27
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant