Provider Demographics
NPI:1639115165
Name:THELEN, MARIA A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:A
Last Name:THELEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:A
Other - Last Name:REMUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1005 S US HIGHWAY 27
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-2423
Mailing Address - Country:US
Mailing Address - Phone:989-224-3000
Mailing Address - Fax:989-224-1424
Practice Address - Street 1:1005 S US HIGHWAY 27
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-2423
Practice Address - Country:US
Practice Address - Phone:989-224-3000
Practice Address - Fax:989-224-1424
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ29731Medicare UPIN
MIPO3700001Medicare ID - Type Unspecified