Provider Demographics
NPI:1790449668
Name:THEISEN, GARRETT MICHAEL
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:MICHAEL
Last Name:THEISEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 76TH ST N APT 214
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-7634
Mailing Address - Country:US
Mailing Address - Phone:701-214-1751
Mailing Address - Fax:
Practice Address - Street 1:7300 N PERIMETER RD
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59402-6701
Practice Address - Country:US
Practice Address - Phone:406-731-4448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians