Provider Demographics
NPI:1992708523
Name:THIELE, MARK A (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:THIELE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1427
Mailing Address - Country:US
Mailing Address - Phone:928-777-9950
Mailing Address - Fax:928-777-9975
Practice Address - Street 1:1223 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1427
Practice Address - Country:US
Practice Address - Phone:928-777-9950
Practice Address - Fax:928-777-9975
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291957500Medicaid
AZ782816Medicaid
AZ782816Medicaid
FLU3678ZMedicare PIN