Healthcare Provider Details

I. General information

NPI: 1215625397
Provider Name (Legal Business Name): CAROL PENGSHUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 6TH AVE N
SAINT CLOUD MN
56303-1900
US

IV. Provider business mailing address

1406 6TH AVE N
SAINT CLOUD MN
56303-1900
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax:
Mailing address:
  • Phone: 320-251-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number83506
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: