1760456479 NPI number — DR. PAMELA JO RUPNOW O.D.

Table of content: DR. PAMELA JO RUPNOW O.D. (NPI 1760456479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760456479 NPI number — DR. PAMELA JO RUPNOW O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUPNOW
Provider First Name:
PAMELA
Provider Middle Name:
JO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1760456479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19645 PILOT KNOB RD
Provider Second Line Business Mailing Address:
STE 106
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55024-7240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-948-1357
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19645 PILOT KNOB RD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55024-7239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-463-2020
Provider Business Practice Location Address Fax Number:
651-463-2066
Provider Enumeration Date:
02/17/2006

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: 152W00000X , with the licence number:  2499 , 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: 1016339 . This is a "PREFERRED ONE HEALTH PLAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2201169 . This is a "MEDICA HEALTH PLAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 084015400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 113289 . This is a "PATIENT'S CHOICE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 114544 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 26019 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 30041RU . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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