Healthcare Provider Details

I. General information

NPI: 1477528727
Provider Name (Legal Business Name): AMANDA J HARRISON PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA RAJALA

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 NICOLLET AVE S MAIL STOP 31500A
BLOOMINGTON MN
55420-2824
US

IV. Provider business mailing address

8170 33RD AVE S # 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-887-6600
  • Fax: 952-886-7015
Mailing address:
  • Phone: 952-541-2800
  • Fax: 952-886-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9933
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: