Healthcare Provider Details

I. General information

NPI: 1659985679
Provider Name (Legal Business Name): MICHAEL THIELEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 TOWN CENTER BLVD STE C
WESTON FL
33326-3641
US

IV. Provider business mailing address

1608 TOWN CENTER BLVD STE A
WESTON FL
33326-3639
US

V. Phone/Fax

Practice location:
  • Phone: 954-389-5900
  • Fax: 954-389-5751
Mailing address:
  • Phone: 954-349-2345
  • Fax: 954-641-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAT9113500
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: