Healthcare Provider Details

I. General information

NPI: 1083659122
Provider Name (Legal Business Name): GWENDOLYN SHORT ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 03/07/2023
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 E. DEARBORN
UNION OR
97883-0986
US

IV. Provider business mailing address

425 20TH AVE S
MINNEAPOLIS MN
55454-4400
US

V. Phone/Fax

Practice location:
  • Phone: 541-562-6062
  • Fax: 541-562-5757
Mailing address:
  • Phone: 612-332-4973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200750114NP FNP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: