Healthcare Provider Details

I. General information

NPI: 1932205408
Provider Name (Legal Business Name): PAULINE A FEDUNOK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAULINE A FEDUNOK PA-C

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HARVARD ST SE
MINNEAPOLIS MN
55455-0363
US

IV. Provider business mailing address

420 DELAWARE STREET, SE MAYO BLDG, MMC B537
MINNEAPOLIS MN
55455
US

V. Phone/Fax

Practice location:
  • Phone: 126-273-3000
  • Fax:
Mailing address:
  • Phone: 612-625-6401
  • Fax: 612-676-4041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number11377
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: