Healthcare Provider Details

I. General information

NPI: 1821352642
Provider Name (Legal Business Name): JESSE PAULUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2012
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 FRANCE AVE S
EDINA MN
55435-2104
US

IV. Provider business mailing address

5807 SHERIDAN AVE S
MINNEAPOLIS MN
55410-2952
US

V. Phone/Fax

Practice location:
  • Phone: 952-924-5000
  • Fax:
Mailing address:
  • Phone: 612-532-0752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR173756-3
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number90394
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: