Healthcare Provider Details

I. General information

NPI: 1265938013
Provider Name (Legal Business Name): KIMMBERLY J THIEL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 PARKER BLVD STE 200
PUEBLO CO
81008-2285
US

IV. Provider business mailing address

10350 E DAKOTA AVE
DENVER CO
80247-1314
US

V. Phone/Fax

Practice location:
  • Phone: 303-338-4545
  • Fax:
Mailing address:
  • Phone: 303-338-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: