Provider Demographics
NPI:1326800426
Name:THIELEMAN, BRANDON KYLE
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:KYLE
Last Name:THIELEMAN
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 1:4560 MISSION GORGE PL APT 566
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4191
Mailing Address - Country:US
Mailing Address - Phone:757-620-2575
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE BLDG 14
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-7000
Practice Address - Country:US
Practice Address - Phone:757-620-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman