Provider Demographics
NPI:1730187295
Name:BHIRO, THAKURDEO MICHAEL (PA)
Entity type:Individual
Prefix:MR
First Name:THAKURDEO
Middle Name:MICHAEL
Last Name:BHIRO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:BHIRO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:821 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMLET
Mailing Address - State:NC
Mailing Address - Zip Code:28345-3001
Mailing Address - Country:US
Mailing Address - Phone:910-582-8452
Mailing Address - Fax:910-462-4184
Practice Address - Street 1:18901 IDA MILL RD
Practice Address - Street 2:
Practice Address - City:LAUREL HILL
Practice Address - State:NC
Practice Address - Zip Code:28351-8326
Practice Address - Country:US
Practice Address - Phone:910-462-2707
Practice Address - Fax:910-462-4184
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101561363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101561OtherPA LICENSE NUMBER
MB0120410OtherDEA NUMBER