Healthcare Provider Details

I. General information

NPI: 1922514181
Provider Name (Legal Business Name): JESSICA LEIGH PUCHALSKI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA LEIGH PUCHALSKI

II. Dates (important events)

Enumeration Date: 12/22/2017
Last Update Date: 10/16/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

IV. Provider business mailing address

5700 BOTTINEAU BLVD STE 100
CRYSTAL MN
55429-3184
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-4000
  • Fax: 763-236-3026
Mailing address:
  • Phone: 763-504-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: