Provider Demographics
NPI:1285643544
Name:THYSELL, FREDERICK JARL (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:JARL
Last Name:THYSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 JESICA DR
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-1729
Mailing Address - Country:US
Mailing Address - Phone:509-829-3861
Mailing Address - Fax:509-469-1905
Practice Address - Street 1:2807 W WASHINGTON AVE
Practice Address - Street 2:STE 117
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98903-1367
Practice Address - Country:US
Practice Address - Phone:509-469-1903
Practice Address - Fax:509-469-1905
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024540208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8120578Medicaid
WA8120578Medicaid
G8800777Medicare PIN