Healthcare Provider Details

I. General information

NPI: 1871511444
Provider Name (Legal Business Name): BETH ANN KORCZAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 ANNE ST NW # 5
BEMIDJI MN
56601-6151
US

IV. Provider business mailing address

1705 ANNE ST NW # 5
BEMIDJI MN
56601-6151
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-5000
  • Fax: 218-333-5360
Mailing address:
  • Phone: 218-333-5000
  • Fax: 218-333-5360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAC0247
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: