Healthcare Provider Details

I. General information

NPI: 1194761726
Provider Name (Legal Business Name): TERENCE PANVICA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 E 26TH ST 600
MINNEAPOLIS MN
55404-4515
US

IV. Provider business mailing address

913 E 26TH ST 600
MINNEAPOLIS MN
55404-4515
US

V. Phone/Fax

Practice location:
  • Phone: 612-775-6200
  • Fax: 612-775-6222
Mailing address:
  • Phone: 612-775-6200
  • Fax: 612-775-6222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9325
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: