Basic Information
| Provider Information | |||||||||
| NPI: | 1629394945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THELEN | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26028 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052623135 | ||||||||
| FaxNumber: | 5052321627 | ||||||||
| Practice Location | |||||||||
| Address1: | 5150 JOURNAL CENTER BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052623233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2010 | ||||||||
| LastUpdateDate: | 03/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2010-0024 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA08598 | 01 | TX | LICENSE | OTHER | 31602843 | 05 | NM | MEDICAID |