Healthcare Provider Details

I. General information

NPI: 1558080929
Provider Name (Legal Business Name): JONATHAN STANLEY POPKO CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 24TH AVE S STE 602
MINNEAPOLIS MN
55454-1438
US

IV. Provider business mailing address

3215 E 24TH ST
MINNEAPOLIS MN
55406-1405
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-2450
  • Fax:
Mailing address:
  • Phone: 612-562-5880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9456
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: