Healthcare Provider Details

I. General information

NPI: 1932316916
Provider Name (Legal Business Name): PEDIATRIC AND YOUNG ADULT MEDICINE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 7TH ST W SUITE 200
SAINT PAUL MN
55116-2300
US

IV. Provider business mailing address

1804 7TH ST W SUITE 200
SAINT PAUL MN
55116-2300
US

V. Phone/Fax

Practice location:
  • Phone: 651-227-7806
  • Fax: 651-256-6766
Mailing address:
  • Phone: 651-227-7806
  • Fax: 651-256-6766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number154
License Number StateMN

VIII. Authorized Official

Name: MS. TERRI M JOSEPH
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 651-256-6706