Healthcare Provider Details

I. General information

NPI: 1942417456
Provider Name (Legal Business Name): WILLIAM JEFFREY LIPPKA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST GENERAL SURGERY DEPT
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

8200 XERXES AVE S
BLOOMINGTON MN
55431-1003
US

V. Phone/Fax

Practice location:
  • Phone: 612-538-6880
  • Fax:
Mailing address:
  • Phone: 952-835-5127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9890
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: