Basic Information
| Provider Information | |||||||||
| NPI: | 1255300885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTUNG | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WENTWORTH | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2550 UNIVERSITY AVE W STE 110N | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551142001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516025309 | ||||||||
| FaxNumber: | 6512226786 | ||||||||
| Practice Location | |||||||||
| Address1: | 110105 PIONEER TRL W STE 302 | ||||||||
| Address2: | |||||||||
| City: | CHASKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553182680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9523615800 | ||||||||
| FaxNumber: | 9523615858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 11/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 43587 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1027664 | 01 | MN | PREFERRED ONE | OTHER | 140263 | 01 | MN | UCARE MN | OTHER | 34182800 | 05 | WI | MEDICAID | 260472800 | 05 | MN | MEDICAID | 3600166 | 01 | MN | MEDICA | OTHER | HP33218 | 01 | MN | HEALTHPARTNERS | OTHER | 69B77WE | 01 | MN | BLUE CROSS BLUE SHIELD MN | OTHER | 1383614 | 01 | MN | AMERICA'S PPO | OTHER |