Individual
THRESIAMMA AUGUSTINE JOSEPH
Active
Sole proprietor
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
3585 LEXINGTON AVE N, STE 350, SHOREVIEW, MN 55126-8064
(651) 484-3942
(651) 787-0519
Mailing address
3585 LEXINGTON AVE N, STE 350, SHOREVIEW, MN 55126-8064
(651) 251-5280
(651) 251-5282
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
32036
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1201379
MEDICA
MN
01
—
1203070
MEDICA
MN
01
—
299L3J0
BLUE CROSS BLUE SHEILD
MN
01
—
CP9090199004
PREFERRED ONE
MN
Enumeration date
09/07/2005
Last updated
07/08/2007
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