MEDICARE: GLORIA J THIELKING MPAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	001168	IA

General Provider Information

NPI Number	:	1053310656
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORIA J THIELKING MPAS

Provider Business Mailing Address
First Line	:	801 YORK ST
Second Line	:
City	:	MANITOWOC
State	:	WI
Zip	:	54220-4630
Country	:	US
Telephone Number	:	920-663-9034
Fax Number	:	920-663-0370

Provider Business Practice Location Address
First Line	:	12327 STRATFORD DR
Second Line	:
City	:	CLIVE
State	:	IA
Zip	:	50325-8148
Country	:	US
Telephone Number	:	515-224-7088
Fax Number	:	515-224-9228

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	07/21/2022

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