MEDICARE: MS. NICOLE RAE VIK MD

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	207Q00000X	Family Medicine Physician	50179	MN

General Provider Information

NPI Number	:	1780614610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NICOLE RAE VIK MD

Provider Business Mailing Address
First Line	:	2025 SLOAN PL
Second Line	:	SUITE 35
City	:	SAINT PAUL
State	:	MN
Zip	:	55117-2007
Country	:	US
Telephone Number	:	651-772-1572
Fax Number	:	651-772-1889

Provider Business Practice Location Address
First Line	:	2601 CENTENNIAL DR
Second Line	:	SUITE 100
City	:	NORTH ST PAUL
State	:	MN
Zip	:	55109-3086
Country	:	US
Telephone Number	:	651-777-7414
Fax Number	:	651-748-5839

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

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	10/27/2011

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