Provider Demographics
NPI:1194964999
Name:THEISSEN, PAIGE JUHREE (PA,-C)
Entity type:Individual
Prefix:MRS
First Name:PAIGE
Middle Name:JUHREE
Last Name:THEISSEN
Suffix:
Gender:F
Credentials:PA,-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2309 PORT RUSH DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160
Mailing Address - Country:US
Mailing Address - Phone:405-238-4153
Mailing Address - Fax:405-665-5108
Practice Address - Street 1:116 E ROBERT S KERR BLVD
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:OK
Practice Address - Zip Code:73098-6621
Practice Address - Country:US
Practice Address - Phone:405-238-4153
Practice Address - Fax:405-665-5108
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant