Healthcare Provider Details

I. General information

NPI: 1760456479
Provider Name (Legal Business Name): PAMELA JO RUPNOW O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 12/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19645 PILOT KNOB RD SUITE 106
FARMINGTON MN
55024-7239
US

IV. Provider business mailing address

19645 PILOT KNOB RD STE 106
FARMINGTON MN
55024-7240
US

V. Phone/Fax

Practice location:
  • Phone: 651-463-2020
  • Fax: 651-463-2066
Mailing address:
  • Phone: 952-948-1357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2499
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: