Basic Information
| Provider Information | |||||||||
| NPI: | 1134235344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IDZIOREK | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | RNNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 13TH AVE E | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182637540 | ||||||||
| FaxNumber: | 8667320699 | ||||||||
| Practice Location | |||||||||
| Address1: | 4891 MILLER TRUNK HWY | ||||||||
| Address2: | |||||||||
| City: | HERMANTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558111512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186261222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R077946-7 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 8G561ID | 01 | MN | BCBS | OTHER | 192225400 | 05 | MN | MEDICAID | 8G560ID | 01 | MN | BCBS | OTHER |