Healthcare Provider Details

I. General information

NPI: 1376736090
Provider Name (Legal Business Name): PAULA MARIE VIGEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MAIN AVE S
PARK RAPIDS MN
56470-1518
US

IV. Provider business mailing address

3835 SUPREME CT NW STE 2
BEMIDJI MN
56601-4485
US

V. Phone/Fax

Practice location:
  • Phone: 218-732-0868
  • Fax: 218-732-8502
Mailing address:
  • Phone: 218-732-0868
  • Fax: 218-732-8502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7616
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: