Provider Demographics
NPI:1912981341
Name:THEOBALD, MICHELLE L (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:845 RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CARVER
Mailing Address - State:MN
Mailing Address - Zip Code:55315-4515
Mailing Address - Country:US
Mailing Address - Phone:952-679-4280
Mailing Address - Fax:
Practice Address - Street 1:6405 FRANCE AVE S # SW200
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2163
Practice Address - Country:US
Practice Address - Phone:952-915-5482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9833207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP97615Medicare UPIN