Healthcare Provider Details

I. General information

NPI: 1043507973
Provider Name (Legal Business Name): BRENT JAMES THIELGES DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9613 SANDIFUR PKWY STE B
PASCO WA
99301-8028
US

IV. Provider business mailing address

9613 SANDIFUR PKWY STE B
PASCO WA
99301-8028
US

V. Phone/Fax

Practice location:
  • Phone: 509-591-9454
  • Fax: 509-578-1118
Mailing address:
  • Phone: 509-591-9454
  • Fax: 509-578-1118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO60436994
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: