1154301463 NPI number — DR. ANDREA B JOLLEY-PAULET M.D.

Table of content: DR. ANDREA B JOLLEY-PAULET M.D. (NPI 1154301463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154301463 NPI number — DR. ANDREA B JOLLEY-PAULET M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOLLEY-PAULET
Provider First Name:
ANDREA
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOLLEY
Provider Other First Name:
ANDREA
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154301463
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 E 34TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIBBING
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55746-2341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-770-2607
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 E 34TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIBBING
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55746-2341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-770-2607
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/20/2006

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: 207Q00000X , with the licence number:  46464 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 62084 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 46464 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 35C.001893 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 33012 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 44971 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 724457600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".