Healthcare Provider Details

I. General information

NPI: 1912267642
Provider Name (Legal Business Name): BRANDON THIEMANN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 FRANCE AVE S
EDINA MN
55435-2104
US

IV. Provider business mailing address

10405 45TH AVE N APT 126
PLYMOUTH MN
55442-3404
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-6300
  • Fax:
Mailing address:
  • Phone: 612-718-1074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR179024-1
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: