Provider Demographics
NPI:1093717506
Name:THIEL, JOHN E JR (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:THIEL
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVANS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29482-8644
Mailing Address - Country:US
Mailing Address - Phone:843-452-7205
Mailing Address - Fax:
Practice Address - Street 1:2095 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5733
Practice Address - Country:US
Practice Address - Phone:843-452-7205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR58231367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1011Medicaid
SCAN1011Medicaid