Healthcare Provider Details

I. General information

NPI: 1497757470
Provider Name (Legal Business Name): MARGUERITE NANCY KIBIRA PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 53RD AVE NE
FRIDLEY MN
55421-1240
US

IV. Provider business mailing address

755 53RD AVE NE
FRIDLEY MN
55421-1240
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 866-389-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9010
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: