Healthcare Provider Details

I. General information

NPI: 1447560693
Provider Name (Legal Business Name): JEANINE MARIE EDSTROM PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEANINE MARIE WORMS

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1185 TOWN CENTRE DR STE 200
EAGAN MN
55123-1343
US

IV. Provider business mailing address

PO BOX 14909
MINNEAPOLIS MN
55414-0909
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1145
  • Fax: 612-870-5491
Mailing address:
  • Phone: 612-871-1145
  • Fax: 612-870-5491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1504
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: