Provider Demographics
NPI:1386634046
Name:THIEMANN, MARK WALTER (PAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WALTER
Last Name:THIEMANN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 KIPLING AVENUE
Mailing Address - Street 2:STE 120
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45239-6600
Mailing Address - Country:US
Mailing Address - Phone:513-981-6784
Mailing Address - Fax:513-853-4095
Practice Address - Street 1:2454 KIPLING AVENUE
Practice Address - Street 2:STE 120
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45239-6600
Practice Address - Country:US
Practice Address - Phone:513-981-6784
Practice Address - Fax:513-853-4095
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-0882363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0077577Medicaid
OHPA-P00919620OtherMEDICARE RR
OHPA-P00919620OtherMEDICARE RR