Healthcare Provider Details

I. General information

NPI: 1588645923
Provider Name (Legal Business Name): TYLER C. THOEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 DUFF AVE
AMES IA
50010-3014
US

IV. Provider business mailing address

1215 DUFF AVE
AMES IA
50010-3014
US

V. Phone/Fax

Practice location:
  • Phone: 515-239-4431
  • Fax: 515-239-4742
Mailing address:
  • Phone: 515-239-4431
  • Fax: 515-239-4742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number18452
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: