Provider Demographics
NPI:1972175149
Name:WIDMER, THANE DAVID (DPT)
Entity Type:Individual
Prefix:
First Name:THANE
Middle Name:DAVID
Last Name:WIDMER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 DAHLBERG DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4841
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:
Practice Address - Street 1:16800 37TH PL N
Practice Address - Street 2:STE 100
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446
Practice Address - Country:US
Practice Address - Phone:763-520-7870
Practice Address - Fax:763-520-7580
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12260225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist