Provider Demographics
NPI:1912394487
Name:THYSSEN, DIANA (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:THYSSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9680 TAMARACK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2623
Mailing Address - Country:US
Mailing Address - Phone:651-738-9001
Mailing Address - Fax:
Practice Address - Street 1:9680 TAMARACK RD STE 100
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-738-9001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN62995208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty