Healthcare Provider Details

I. General information

NPI: 1740658814
Provider Name (Legal Business Name): MATTHEW ALBERT PECKSKAMP PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 6TH AVENUE NORTH ST CLOUD HOSPITAL
ST CLOUD MN
56303-1900
US

IV. Provider business mailing address

1406 6TH AVENUE NORTH ST CLOUD HOSPITAL
ST CLOUD MN
56303-1900
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax: 320-656-7115
Mailing address:
  • Phone: 320-251-2700
  • Fax: 320-656-7115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2316
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number11903
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: