Healthcare Provider Details

I. General information

NPI: 1861479693
Provider Name (Legal Business Name): TRICIA WALLENTINE ISCHE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 N FRONTAGE RD
HASTINGS MN
55033-2687
US

IV. Provider business mailing address

14000 FAIRVIEW DR
BURNSVILLE MN
55337-5713
US

V. Phone/Fax

Practice location:
  • Phone: 651-438-1800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9586
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9586
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: