Healthcare Provider Details

I. General information

NPI: 1982664769
Provider Name (Legal Business Name): SUSAN M JAGODZINSKI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 HART BLVD
MONTICELLO MN
55362-8575
US

IV. Provider business mailing address

10749 KILBURY AVE SW
HOWARD LAKE MN
55349-5519
US

V. Phone/Fax

Practice location:
  • Phone: 763-271-2248
  • Fax: 763-271-2890
Mailing address:
  • Phone: 320-543-2288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR101747-4
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9714
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9714
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: