Basic Information
| Provider Information | |||||||||
| NPI: | 1184085219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANICK | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HJELMGREN | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | RAE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7620 BOWMAN CT | ||||||||
| Address2: | |||||||||
| City: | INVER GROVE HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550762907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514928144 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2525 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554044518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128136000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2016 | ||||||||
| LastUpdateDate: | 03/17/2016 | ||||||||
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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 | 363A00000X | 2455 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.