Healthcare Provider Details

I. General information

NPI: 1437106986
Provider Name (Legal Business Name): CLARICE HANKS KONSHOK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CLARICE HANKS

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 NORTHWAY DR STE 200
SAINT CLOUD MN
56303-4913
US

IV. Provider business mailing address

1555 NORTHWAY DR STE 200
SAINT CLOUD MN
56303-4913
US

V. Phone/Fax

Practice location:
  • Phone: 320-240-3157
  • Fax: 320-240-3164
Mailing address:
  • Phone: 320-240-3157
  • Fax: 320-240-3164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39535
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: