Provider Demographics
NPI:1912918665
Name:TIESSEN, JON R (DPM)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:R
Last Name:TIESSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 CYPRESS DR
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-1114
Mailing Address - Country:US
Mailing Address - Phone:360-293-9765
Mailing Address - Fax:
Practice Address - Street 1:1100 SW BOWMER ST
Practice Address - Street 2:SUITE A-103
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3119
Practice Address - Country:US
Practice Address - Phone:360-679-3117
Practice Address - Fax:360-679-3118
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000673213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1119163Medicaid
WAG8803493Medicare PIN
WAU79975Medicare UPIN