1306509302 NPI number — ELLIOT COLE NUCKOLS MPS

Table of content: ELLIOT COLE NUCKOLS MPS (NPI 1306509302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306509302 NPI number — ELLIOT COLE NUCKOLS MPS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUCKOLS
Provider First Name:
ELLIOT
Provider Middle Name:
COLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NUCKOLS
Provider Other First Name:
BREANNA
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306509302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 E 18TH ST UNIT 615
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55403-4094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-268-1835
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 COMMERCE DR STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-5407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-268-1835
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2021

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: 101YM0800X , with the licence number:  3675 , 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)