Provider Demographics
NPI:1730254285
Name:THIEMANN, JAY T (ST)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:T
Last Name:THIEMANN
Suffix:
Gender:M
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 S MAIN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2983
Mailing Address - Country:US
Mailing Address - Phone:208-883-2828
Mailing Address - Fax:208-882-2179
Practice Address - Street 1:623 S MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2983
Practice Address - Country:US
Practice Address - Phone:208-883-2828
Practice Address - Fax:208-882-2179
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAST00002460246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist