Provider Demographics
NPI:1780642082
Name:THEOBALD, GEOFFREY J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GEOFFREY
Middle Name:J
Last Name:THEOBALD
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:4200 DAHLBERG DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4840
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:952-512-5651
Practice Address - Street 1:1000 W 140TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4480
Practice Address - Country:US
Practice Address - Phone:952-898-6300
Practice Address - Fax:952-898-6035
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-08-15
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Provider Licenses
StateLicense IDTaxonomies
MN10003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNQ16232Medicare UPIN