MEDICARE: NICKLAUS GRONNING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	1208

General Provider Information

NPI Number	:	1265683270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICKLAUS GRONNING

Provider Business Mailing Address
First Line	:	576 APOLLO DR
Second Line	:
City	:	LINO LAKES
State	:	MN
Zip	:	55014-3004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	576 APOLLO DR
Second Line	:
City	:	LINO LAKES
State	:	MN
Zip	:	55014-3004
Country	:	US
Telephone Number	:	651-784-1611
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2008
Last Update Date	:	10/08/2008

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Directions to “ NICKLAUS GRONNING ” Practice Location

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