| Doctor Name: | THEERARAT THANAVARO |
| NPI Number: | 1265823074 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 2014015283 |
| Business Practice Address: | 9512 Harford Rd Parkville, MD - 212343100 |
| Business Phone Number: | 4106654400 |
| Business Fax Number: | |
| Mailing Address: | 421 Matts Way, DEFIANCE |
| State: | MO |
| Postal Code: | 633412524 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 02/16/2015 |
| NPI Last Update Date: | 02/16/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LA2200X |
| License Number: | 2014015283 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Adult Health |
| Taxonomy Definition: | |