Healthcare Provider Details

I. General information

NPI: 1093141277
Provider Name (Legal Business Name): MEGAN THIEME PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5142
APO AP
96368-5142
US

IV. Provider business mailing address

1650 COCHRANE CIR
FORT CARSON CO
80913-4613
US

V. Phone/Fax

Practice location:
  • Phone: 315-630-4780
  • Fax:
Mailing address:
  • Phone: 719-524-3196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP5200
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: