Healthcare Provider Details

I. General information

NPI: 1881504611
Provider Name (Legal Business Name): GRANT THOMAS THIESSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24800 S 4420 RD
VINITA OK
74301-5544
US

IV. Provider business mailing address

1115 E MEADOWLANE RD
VINITA OK
74301-1700
US

V. Phone/Fax

Practice location:
  • Phone: 918-244-5462
  • Fax:
Mailing address:
  • Phone: 918-244-5462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: