Healthcare Provider Details

I. General information

NPI: 1508417924
Provider Name (Legal Business Name): GARY PREBECK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N
SAINT CLOUD MN
56303-2735
US

IV. Provider business mailing address

1200 6TH AVE N
SAINT CLOUD MN
56303-2735
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-7825
  • Fax:
Mailing address:
  • Phone: 320-252-3342
  • Fax: 320-252-3501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13669
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: