Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 30063 | MA |
Y | 208600000X | Surgeon | 30063 | MA |
NPI | 1003815366 |
---|---|
Provider Name | Bruce Alden Thayer |
First Address | Newton, MA 02462-1650 |
Second Address | Newton, MA 02462-1650 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2019159 | (05) | MA |
B75685 | (02) |