Healthcare Provider Details

I. General information

NPI: 1083081582
Provider Name (Legal Business Name): PATRICIA JEANETTE DE LOYAL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 HENNEPIN AVE N
GLENCOE MN
55336
US

IV. Provider business mailing address

1805 HENNEPIN AVE N
GLENCOE MN
55336-1416
US

V. Phone/Fax

Practice location:
  • Phone: 320-864-3121
  • Fax: 320-864-7998
Mailing address:
  • Phone: 320-864-3121
  • Fax: 320-864-7989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12696
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: