Healthcare Provider Details

I. General information

NPI: 1730588823
Provider Name (Legal Business Name): TIFFANY J RADKE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 05/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 UNIVERSITY AVE W FL 1
SAINT PAUL MN
55104-3727
US

IV. Provider business mailing address

1700 UNIVERSITY AVE W FL 1
SAINT PAUL MN
55104-3727
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-2002
  • Fax:
Mailing address:
  • Phone: 651-232-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209-011702
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number5391
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: