Healthcare Provider Details

I. General information

NPI: 1487857249
Provider Name (Legal Business Name): PAM J. WAAGE CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

6997 47TH AVE SE
SAINT CLOUD MN
56304-9583
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-5220
  • Fax: 320-203-2414
Mailing address:
  • Phone: 320-529-0051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR1041631
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: