NPIMap

Individual provider Active NPI

Michelle L Theobald, PA-C

  • Family Medicine Physician
  • Edina, MN
National Provider Identifier
1912981341
Registry record updated Oct 25, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
9833 Issued in MN
Practice address
6405 France Ave S # Sw200
Edina, MN 55435-2163
Phone
(952) 915-5482
NPI assigned
Nov 30, 2005
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 25, 2007

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 9833 MN Primary

Addresses

Primary practice location

6405 France Ave S # Sw200
Edina, MN 55435-2163

Mailing address

845 Ramsey Ave
Carver, MN 55315-4515
Phone (952) 679-4280

Other names 1

  • Michelle L Johnson Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040421001502 MN Practitioner - Physician Assistant 3375539752 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2004
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Park Nicollet ClinicGroup PAC ID 7911819438, 1,778 clinicians
Glencoe Regional Health ServicesGroup PAC ID 1759292980, 45 clinicians

Practice addresses (Care Compare)

14000 Fairview Dr
Burnsville, MN 55337-5713
Phone (952) 993-8700

1805 Hennepin Ave N
Glencoe, MN 55336-1416
Phone (320) 864-3121

1805 N Hennepin Ave
Glencoe, MN 55336-1416

1885 Plaza Dr
Eagan, MN 55122-2979
Phone (952) 993-4001

3800 Park Nicollet Blvd
St Louis Park, MN 55416-2527
Phone (952) 993-3123

3850 Park Nicollet Blvd
St Louis Park, MN 55416-2527
Phone (952) 993-3123

5320 Hyland Greens Dr
Bloomington, MN 55437-3934
Phone (952) 993-2400

6500 Excelsior Blvd
St Louis Park, MN 55426-4702
Phone (952) 993-3123

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
9833MNMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Park Nicollet Methodist Hospital CurrentSince Aug 18, 2014 Accepting new patients
Glencoe Regional Health Services CurrentSince Sep 18, 2013 Accepting new patients
Park Nicollet Clinic Family Medicine CurrentSince Aug 18, 2014 Accepting new patients
Glencoe Regional Health Services CurrentSince Sep 18, 2013 Accepting new patients

Locations

1805 Hennepin Ave N
Glencoe, MN 55336
Phone (320) 864-3121

5320 Hyland Greens Dr
Minneapolis, MN 55437
Phone (952) 993-2400

Interoperability endpoints

  • Direct secure messaging: mtheobald92133@excellian.direct.allina.com

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1133308800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1193270400000",
    "number": "1912981341",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "845 RAMSEY AVE",
            "city": "CARVER",
            "state": "MN",
            "postal_code": "553154515",
            "telephone_number": "952-679-4280"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6405 FRANCE AVE S # SW200",
            "city": "EDINA",
            "state": "MN",
            "postal_code": "554352163",
            "telephone_number": "952-915-5482"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "THEOBALD",
        "first_name": "MICHELLE",
        "middle_name": "L",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-11-30",
        "last_updated": "2007-10-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MN",
            "license": "9833",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "MICHELLE",
            "last_name": "JOHNSON",
            "middle_name": "L",
            "credential": "PA-C",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Edina, MN

Sources for this page

Verify at the official NPI Registry.