Basic Information
Provider Information | |||||||||
NPI: | 1134411432 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THIERMANN | ||||||||
FirstName: | PAIGE | ||||||||
MiddleName: | ALEXANDRA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEKOSTER | ||||||||
OtherFirstName: | PAIGE | ||||||||
OtherMiddleName: | ALEXANDRA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 425 N DATE ST | ||||||||
Address2: |   | ||||||||
City: | ESCONDIDO | ||||||||
State: | CA | ||||||||
PostalCode: | 920253413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607376960 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 855 E MADISON AVE | ||||||||
Address2: |   | ||||||||
City: | EL CAJON | ||||||||
State: | CA | ||||||||
PostalCode: | 920203819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6194402751 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2011 | ||||||||
LastUpdateDate: | 09/04/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A114779 | CA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | GJ432Z | 01 | CA | MEDICARE PTAN | OTHER | W14158 | 01 | CA | GROUP PTAN | OTHER |