MEDICARE: PATRICIA MACGILLIVRAY CPNP

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	363LP0200X	Pediatric Nurse Practitioner	R077250-3	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417949512
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA MACGILLIVRAY CPNP

Provider Business Mailing Address
First Line	:	2525 CHICAGO AVENUE
Second Line	:	2525 CHICAGO AVENUE SOUTH
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404
Country	:	US
Telephone Number	:
Fax Number	:	651-855-2310

Provider Business Practice Location Address
First Line	:	2525 CHICAGO AVE
Second Line	:	2525 CHICAGO AVENUE SOUTH
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4518
Country	:	US
Telephone Number	:	612-813-6107
Fax Number	:	651-855-2310

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

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	01/26/2016

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