Healthcare Provider Details

I. General information

NPI: 1013359579
Provider Name (Legal Business Name): MR. TODD MICHAEL THIEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 HAWTHORNE RD
WYOMING MN
55092-9717
US

IV. Provider business mailing address

204 HAWTHORNE RD
WYOMING MN
55092-9717
US

V. Phone/Fax

Practice location:
  • Phone: 651-464-7444
  • Fax: 651-464-7444
Mailing address:
  • Phone: 651-464-7444
  • Fax: 651-464-7444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number377643
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: