Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | OS016519 | PA |
N | 207QS0010X | Family Doctor - Sports Medicine | OS016519 | PA |
NPI | 1326353996 |
---|---|
Provider Name | Gregor Stanley Thebaud |
First Address | Broad Top, PA 16621-9001 |
Second Address | Huntingdon, PA 16652-1725 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/08/2010 |
Last Update Date | 26/10/2021 |