Healthcare Provider Details

I. General information

NPI: 1053193557
Provider Name (Legal Business Name): AMANDA LYNN FORTIER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA LYNN KAUKOLA

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11850 BLACKFOOT ST NW STE 470
COON RAPIDS MN
55433-2773
US

IV. Provider business mailing address

3001 METRO DR STE 460
BLOOMINGTON MN
55425-1548
US

V. Phone/Fax

Practice location:
  • Phone: 651-999-6800
  • Fax: 833-905-2114
Mailing address:
  • Phone: 651-999-7022
  • Fax: 651-999-6970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14693
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: