1912398694 NPI number — MICHAEL THEISEN

Table of content: MICHAEL THEISEN (NPI 1912398694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912398694 NPI number — MICHAEL THEISEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THEISEN
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912398694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22530 SE 64TH PLACE, SUITE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ISSAQUAH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-281-6405
Provider Business Mailing Address Fax Number:
425-961-0783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22530 SE 64TH PL STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ISSAQUAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98027-5353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-281-6405
Provider Business Practice Location Address Fax Number:
425-961-0783
Provider Enumeration Date:
02/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LH60195901 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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