1891723847 NPI number — JACQUELINE POLIPNICK PA-C

Table of content: JACQUELINE POLIPNICK PA-C (NPI 1891723847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891723847 NPI number — JACQUELINE POLIPNICK PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLIPNICK
Provider First Name:
JACQUELINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891723847
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 COUNTY ROAD 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303-4872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-202-8949
Provider Business Mailing Address Fax Number:
320-202-0756

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 33RD ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-251-8181
Provider Business Practice Location Address Fax Number:
320-251-6942
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  10000 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 332113400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com