Healthcare Provider Details

I. General information

NPI: 1922115849
Provider Name (Legal Business Name): RENEE ANNE GUNDERSON PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RENEE ANNE DANIELZUK MCKEEVER PAC

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 BEAM AVE
MAPLEWOOD MN
55109-1126
US

IV. Provider business mailing address

3359 WILDWOOD TRL NW
PRIOR LAKE MN
55372-3267
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-7348
  • Fax: 651-232-6665
Mailing address:
  • Phone: 612-532-2414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9265
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: