Provider Demographics
NPI:1760614101
Name:THELEN, JONATHAN D (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:THELEN
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:1650 RAMBLEWOOD DR STE 100
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-7396
Mailing Address - Country:US
Mailing Address - Phone:517-332-1200
Mailing Address - Fax:517-351-7122
Practice Address - Street 1:1650 RAMBLEWOOD DR STE 100
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-7396
Practice Address - Country:US
Practice Address - Phone:517-332-1200
Practice Address - Fax:517-351-7122
Is Sole Proprietor?:No
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
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Provider Licenses
StateLicense IDTaxonomies
MI5601005596363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant