Provider Demographics
NPI:1649808627
Name:THIEL, SASHA ANIKA
Entity type:Individual
Prefix:
First Name:SASHA
Middle Name:ANIKA
Last Name:THIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18714 PEPPER PIKE
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:777 GLADES RD # BC71
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6424
Practice Address - Country:US
Practice Address - Phone:561-955-3696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30494208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery