Provider Demographics
NPI:1902145048
Name:THIEL, MARK ROBERT
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:THIEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 CASTLE POINTE LN
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:678-216-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-09
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6963367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant