Provider Demographics
NPI:1689756991
Name:THIEBEN, JENNIFER ANN (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:THIEBEN
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 SALT SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1302
Mailing Address - Country:US
Mailing Address - Phone:315-445-4440
Mailing Address - Fax:315-445-4714
Practice Address - Street 1:1419 SALT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1302
Practice Address - Country:US
Practice Address - Phone:315-445-4440
Practice Address - Fax:315-445-4714
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007185-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA1950Medicare PIN
NY1689756991Medicare UPIN