Healthcare Provider Details

I. General information

NPI: 1669447215
Provider Name (Legal Business Name): BARRY A RADIN PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 15TH ST N
SAINT CLOUD MN
56303-1802
US

IV. Provider business mailing address

1511 NORTHWAY DR STE 103
SAINT CLOUD MN
56303-1262
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-5200
  • Fax: 320-203-2113
Mailing address:
  • Phone: 320-267-1341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8819
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: