1265524136 NPI number — MRS. GINA MARIE WIPPLER PA-C

Table of content: MRS. GINA MARIE WIPPLER PA-C (NPI 1265524136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265524136 NPI number — MRS. GINA MARIE WIPPLER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIPPLER
Provider First Name:
GINA
Provider Middle Name:
MARIE
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:
TOUMI
Provider Other First Name:
GINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265524136
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1555 NORTHWAY DRIVE #100
Provider Second Line Business Mailing Address:
CENTRACARE CLINIC NORTHWAY FAMILY MEDICINE
Provider Business Mailing Address City Name:
ST CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303-1258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-251-1775
Provider Business Mailing Address Fax Number:
320-240-3131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1555 NORTHWAY DRIVE #100
Provider Second Line Business Practice Location Address:
CENTRACARE CLINIC NORTHWAY FAMILY MEDICINE
Provider Business Practice Location Address City Name:
ST CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303-1258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-251-1775
Provider Business Practice Location Address Fax Number:
320-240-3131
Provider Enumeration Date:
09/29/2006

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: 363A00000X , with the licence number:  9761 , 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: 132M4T0 . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 136543600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0113101 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 142448C736 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".