Healthcare Provider Details

I. General information

NPI: 1053550301
Provider Name (Legal Business Name): NICHOLAS R THIESSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2009
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 S DOBSON RD STE 201
CHANDLER AZ
85224
US

IV. Provider business mailing address

PO BOX 33269
PHOENIX AZ
85067-3269
US

V. Phone/Fax

Practice location:
  • Phone: 480-728-4700
  • Fax: 480-728-4747
Mailing address:
  • Phone: 602-406-4786
  • Fax: 916-636-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR70173
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number48625
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: