Provider Demographics
NPI:1003658964
Name:THIES, ETHAN WILLIAM GARYSON (APN)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:WILLIAM GARYSON
Last Name:THIES
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 THIES RD
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2046
Mailing Address - Country:US
Mailing Address - Phone:856-693-6459
Mailing Address - Fax:
Practice Address - Street 1:401 KINGS HWY S
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2500
Practice Address - Country:US
Practice Address - Phone:856-209-0447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14996900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily