Provider Demographics
NPI:1851168165
Name:THEISEN, ERIC JOSEPH (RN)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JOSEPH
Last Name:THEISEN
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 1:1526 NORTHWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1224
Mailing Address - Country:US
Mailing Address - Phone:800-349-7272
Mailing Address - Fax:
Practice Address - Street 1:1526 NORTHWAY DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1224
Practice Address - Country:US
Practice Address - Phone:800-349-7272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201928-0163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse