Healthcare Provider Details

I. General information

NPI: 1770557514
Provider Name (Legal Business Name): MAMTA RANI X PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

1400 YELLOWSTONE DR
BROOKINGS SD
57006-4087
US

V. Phone/Fax

Practice location:
  • Phone: 612-725-2000
  • Fax:
Mailing address:
  • Phone: 618-303-1995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number002127
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: