Basic Information
| Provider Information | |||||||||
| NPI: | 1427099969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANNKUK | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14700 28TH AVE N | ||||||||
| Address2: | SUITE 20 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554474835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635593779 | ||||||||
| FaxNumber: | 7634503986 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 E 1ST ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182796200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R097004-6 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.