Provider Demographics
NPI:1376152173
Name:THIETS, CONNOR J (PA-C)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:J
Last Name:THIETS
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5200
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:15700 37TH AVE N STE 150
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3675
Practice Address - Country:US
Practice Address - Phone:651-968-5201
Practice Address - Fax:763-557-4933
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2021-05-25
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
MN13728363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant