Provider Demographics
NPI:1568985521
Name:THIEM, JORDYN DIANE (PA)
Entity Type:Individual
Prefix:
First Name:JORDYN
Middle Name:DIANE
Last Name:THIEM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WATERS VIEW CIR APT 29-203
Mailing Address - Street 2:
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047-5200
Mailing Address - Country:US
Mailing Address - Phone:978-790-7381
Mailing Address - Fax:
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204-1004
Practice Address - Country:US
Practice Address - Phone:978-790-7381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021086363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical