=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962449330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH CENTRAL PATHOLOGY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 10/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3701 12TH ST N SUITE 201
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56303-2255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-253-6554
-----------------------------------------------------
Fax | 320-253-1218
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3701 12TH ST N SUITE 201
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56303-2255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-253-6554
-----------------------------------------------------
Fax | 320-253-1218
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. MICHELLE NYBERG HANSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 320-253-6554
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 37636
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------