Provider Demographics
NPI:1982121059
Name:MIRELES THORN, SALVADOR (PA-C)
Entity type:Individual
Prefix:
First Name:SALVADOR
Middle Name:
Last Name:MIRELES THORN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:SALVADOR
Other - Middle Name:MIRELES
Other - Last Name:THORN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:2817 ROCK MERRITT AVENUE WOMACK ARMY MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310-4994
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:WOMACK ARMY MEDICAL CENTER 2817 ROCK MERRITT AVENUE
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-8922
Practice Address - Fax:910-907-6069
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-11074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant