Individual
EUGENE HENRY THIEBAUD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
BLDG 200, ROBINHOOD MEDICAL PLAZA, WINSTON SALEM, NC 27106-5475
(336) 718-7950
(336) 718-7989
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
(336) 718-7950
(336) 718-7989
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
101957
NC
363AS0400X
Surgical Physician Assistant
000101957
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
7400798
AETNA
—
01
—
94709
MEDCOST
—
01
—
970025236
RR MEDICARE
—
Enumeration date
12/13/2005
Last updated
10/14/2014
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