Provider Demographics
NPI:1689982043
Name:THIEL, BENJAMIN (RN)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:
Last Name:THIEL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-7040
Mailing Address - Fax:414-955-0175
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-7040
Practice Address - Fax:414-955-0175
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17073430163WC0200X
WI15166363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1689982043Medicaid