Basic Information
| Provider Information | |||||||||
| NPI: | 1295947158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BIRKELO | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WESTBROOK CORP CTR | ||||||||
| Address2: | STE 240 | ||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601545745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082362673 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 W 140TH ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553374480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528083000 | ||||||||
| FaxNumber: | 9528083001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085003567 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 12013 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.