Provider Demographics
NPI:1770959405
Name:THEISEN, TIMOTHY RICHARD (PTA)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:THEISEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 GAUGER ST NE
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-1707
Mailing Address - Country:US
Mailing Address - Phone:320-583-0422
Mailing Address - Fax:
Practice Address - Street 1:250 GAUGER ST NE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-1707
Practice Address - Country:US
Practice Address - Phone:320-583-0422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA249225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant