Basic Information
| Provider Information | |||||||||
| NPI: | 1376152173 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THIETS | ||||||||
| FirstName: | CONNOR | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 COMMERCE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551254925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685200 | ||||||||
| FaxNumber: | 6519685904 | ||||||||
| Practice Location | |||||||||
| Address1: | 15700 37TH AVE N STE 150 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685201 | ||||||||
| FaxNumber: | 7635574933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2020 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 13728 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.