Provider Demographics
NPI:1497203137
Name:THIELEN, WLADIMIR (ADVANCED PRACTICE)
Entity Type:Individual
Prefix:
First Name:WLADIMIR
Middle Name:
Last Name:THIELEN
Suffix:
Gender:M
Credentials:ADVANCED PRACTICE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 FAIRMONT ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-8979
Mailing Address - Country:US
Mailing Address - Phone:786-300-6009
Mailing Address - Fax:
Practice Address - Street 1:1326 FAIRMONT ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-8979
Practice Address - Country:US
Practice Address - Phone:786-300-6009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9316935363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner