Healthcare Provider Details

I. General information

NPI: 1124501598
Provider Name (Legal Business Name): JILL E GAUGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7368 KIRKWOOD CT N
MAPLE GROVE MN
55369-5270
US

IV. Provider business mailing address

2165 FULHAM ST
ROSEVILLE MN
55113-3816
US

V. Phone/Fax

Practice location:
  • Phone: 763-416-2280
  • Fax:
Mailing address:
  • Phone: 312-860-2142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6159
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: