Basic Information
| Provider Information | |||||||||
| NPI: | 1124058110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EGGINK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | EGGINK | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1021 BANDANA BLVD E | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551085113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516422700 | ||||||||
| FaxNumber: | 6516429441 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 BANDANA BLVD W | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551085107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516417000 | ||||||||
| FaxNumber: | 6516417166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | R0769231 | MN | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | R0769231 | MN | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.