Basic Information
| Provider Information | |||||||||
| NPI: | 1013901875 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSEVICH | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | MARTINIQUE | ||||||||
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| Credential: | MSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE S # MS 21110Q | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514956603 | ||||||||
| FaxNumber: | 9528538727 | ||||||||
| Practice Location | |||||||||
| Address1: | 295 PHALEN BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551302400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514956603 | ||||||||
| FaxNumber: | 6514956201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 01/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R1237131 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.