1245221860 NPI number — MRS. REBECCA ANN PELKOLA PA-C

Table of content: MRS. REBECCA ANN PELKOLA PA-C (NPI 1245221860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245221860 NPI number — MRS. REBECCA ANN PELKOLA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELKOLA
Provider First Name:
REBECCA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
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:
1245221860
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
913 EAST 26TH STREET
Provider Second Line Business Mailing Address:
TWIN CITIES SPINE CENTER PIPER BUILDING, SUITE 600
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55404-4515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-775-6200
Provider Business Mailing Address Fax Number:
612-775-6222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
913 EAST 26TH STREET
Provider Second Line Business Practice Location Address:
TWIN CITIES SPINE CENTER PIPER BUILDING, SUITE 600
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55404-4515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-775-6200
Provider Business Practice Location Address Fax Number:
612-775-6222
Provider Enumeration Date:
11/02/2005

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: 363A00000X , with the licence number:  PA17779 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA900 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 11014 , 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: PA177790 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CC7589 . This is a "BCBS" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 100505782 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".