Healthcare Provider Details

I. General information

NPI: 1306522768
Provider Name (Legal Business Name): KYLE JEFFREY THEILMANN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9630 GROVE CIR N STE 200
MAPLE GROVE MN
55369-3492
US

IV. Provider business mailing address

4200 DAHLBERG DR STE 300
GOLDEN VALLEY MN
55422-4841
US

V. Phone/Fax

Practice location:
  • Phone: 763-520-7870
  • Fax:
Mailing address:
  • Phone: 952-512-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14548
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: