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NPI Code Detail

MEDICARE: DEMITRI NICHELLE GOCKEL PA-C

MEDICARE: DEMITRI NICHELLE GOCKEL PA-C
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
1363A00000XPhysician Assistant

General Provider Information

NPI Number : 1497395719
Entity Type Code : Individual
Provider Name (Legal Business Name) : DEMITRI NICHELLE GOCKEL PA-C
Provider Business Mailing Address
First Line : 2550 UNIVERSITY AVE W STE 110N
Second Line :
City : SAINT PAUL
State : MN
Zip : 55114-2001
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 11850 BLACKFOOT ST NW STE 100
Second Line :
City : COON RAPIDS
State : MN
Zip : 55433-2774
Country : US
Telephone Number : 763-712-2100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/14/2020
Last Update Date : 03/14/2022

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Directions to “ DEMITRI NICHELLE GOCKEL PA-C” Practice Location

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