Provider Demographics
NPI:1013359579
Name:THIEMAN, TODD MICHAEL
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:MICHAEL
Last Name:THIEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-9717
Mailing Address - Country:US
Mailing Address - Phone:651-464-7444
Mailing Address - Fax:651-464-7444
Practice Address - Street 1:204 HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-9717
Practice Address - Country:US
Practice Address - Phone:651-464-7444
Practice Address - Fax:651-464-7444
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN377643172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver