Healthcare Provider Details

I. General information

NPI: 1780621904
Provider Name (Legal Business Name): PARK NICOLLET CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 PARK NICOLLET BLVD
ST LOUIS PARK MN
55416
US

IV. Provider business mailing address

3800 PARK NICOLLET BLVD ATT BUSINESS SERVICES
ST LOUIS PARK MN
55416
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3123
  • Fax: 952-993-2770
Mailing address:
  • Phone: 952-993-1835
  • Fax: 952-993-1808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALITA RISINGER
Title or Position: SR VICE PRESIDENT, CFO
Credential:
Phone: 952-883-5401