Healthcare Provider Details

I. General information

NPI: 1013356922
Provider Name (Legal Business Name): KELLY C GRECO PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 PARK NICOLLET BLVD DEPARTMENT OF DERMATOLOGY
ST LOUIS PARK MN
55416-2527
US

IV. Provider business mailing address

500 OSBORNE RD NE DEPT OF
FRIDLEY MN
55432-2765
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3260
  • Fax: 952-993-0333
Mailing address:
  • Phone: 763-786-6011
  • Fax: 763-684-2505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11710
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: