Healthcare Provider Details

I. General information

NPI: 1619586005
Provider Name (Legal Business Name): JEREMIAS THUESEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3380 W DAYTON AIRPORT RD
SHELTON WA
98584-8952
US

IV. Provider business mailing address

3380 W DAYTON AIRPORT RD
SHELTON WA
98584-8952
US

V. Phone/Fax

Practice location:
  • Phone: 360-359-5145
  • Fax:
Mailing address:
  • Phone: 360-359-5145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberMC53242
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: