Healthcare Provider Details

I. General information

NPI: 1922546712
Provider Name (Legal Business Name): NICHOLAS THIEL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N4231 STATE HIGHWAY 22
SHAWANO WI
54166-6130
US

IV. Provider business mailing address

19395 W CAPITOL DR STE 200
BROOKFIELD WI
53045-2736
US

V. Phone/Fax

Practice location:
  • Phone: 715-526-3158
  • Fax:
Mailing address:
  • Phone: 262-923-7101
  • Fax: 262-923-7179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2536-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: