Healthcare Provider Details

I. General information

NPI: 1982150728
Provider Name (Legal Business Name): PARK NICOLLET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 UPLAND LN N
MAPLE GROVE MN
66369
US

IV. Provider business mailing address

7102 OLIVE LANE NORTH
MAPLE GROVE MN
55311
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-1589
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberL 48617-4
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberL 48617-4
License Number StateMN

VIII. Authorized Official

Name: SOFIYA TSUKERMAN
Title or Position: HTCP
Credential:
Phone: 763-494-4686