Provider Demographics
NPI:1629394945
Name:THELEN, ANDREA K (PA)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:K
Last Name:THELEN
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:PO BOX 26028
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-262-3135
Mailing Address - Fax:505-232-1627
Practice Address - Street 1:5150 JOURNAL CENTER BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-262-3233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-12
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2010-0024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA08598OtherLICENSE
NM31602843Medicaid