Basic Information
Provider Information | |||||||||
NPI: | 1043569148 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCUE | ||||||||
FirstName: | JANEAN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3605 MAYFAIR AVE | ||||||||
Address2: | FAIRVIEW MESABA CLINIC | ||||||||
City: | HIBBING | ||||||||
State: | MN | ||||||||
PostalCode: | 55746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2182623441 | ||||||||
FaxNumber: | 2183626907 | ||||||||
Practice Location | |||||||||
Address1: | 3605 MAYFAIR AVE | ||||||||
Address2: | FAIRVIEW MESABA CLINIC | ||||||||
City: | HIBBING | ||||||||
State: | MN | ||||||||
PostalCode: | 55746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2182623441 | ||||||||
FaxNumber: | 2183626907 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2012 | ||||||||
LastUpdateDate: | 09/05/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | R92451-3 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.