Healthcare Provider Details

I. General information

NPI: 1942230628
Provider Name (Legal Business Name): VICTORIA SERGEYEVNA MIRKOVIC GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA SERGEYEVNA NOBLE GNP

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 UNIVERSITY AVE W
SAINT PAUL MN
55104-3727
US

IV. Provider business mailing address

1541 HOLLYBROOK RD
WAYZATA MN
55391-1341
US

V. Phone/Fax

Practice location:
  • Phone: 612-469-1820
  • Fax: 888-972-1770
Mailing address:
  • Phone: 612-469-1820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0740
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: