1063423366 NPI number — MARJORIE L VAN DER HAGEN PA-C

Table of content: MARJORIE L VAN DER HAGEN PA-C (NPI 1063423366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063423366 NPI number — MARJORIE L VAN DER HAGEN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN DER HAGEN
Provider First Name:
MARJORIE
Provider Middle Name:
L
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:
1063423366
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6465 WAYZATA BLVD
Provider Second Line Business Mailing Address:
SUITE 900
Provider Business Mailing Address City Name:
ST LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55426-1728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-512-5600
Provider Business Mailing Address Fax Number:
952-512-5650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7373 FRANCE AVE S
Provider Second Line Business Practice Location Address:
SUITE 312
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-4534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-832-0076
Provider Business Practice Location Address Fax Number:
952-832-9881
Provider Enumeration Date:
08/11/2006

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:  9413 , 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: 73B61VA . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP45664 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 114933 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 969991018909 . This is a "PREFERREDONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 12339E948 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".




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