Provider Demographics
NPI:1063548915
Name:THORP, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:THORP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4855
Mailing Address - Fax:
Practice Address - Street 1:1010 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2507
Practice Address - Country:US
Practice Address - Phone:919-690-3237
Practice Address - Fax:919-690-3213
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2400367500000X
NC42711367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8050100Medicaid
NC8050100Medicaid