Provider Demographics
NPI:1679689004
Name:THIELE, PETER J (PA-C)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:THIELE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N MONITOR ST
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:NE
Mailing Address - Zip Code:68788-1595
Mailing Address - Country:US
Mailing Address - Phone:402-372-6717
Mailing Address - Fax:402-372-2360
Practice Address - Street 1:211 N ENGDAHL AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:NE
Practice Address - Zip Code:68045-1431
Practice Address - Country:US
Practice Address - Phone:402-685-5116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE868363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE280834Medicare PIN