Basic Information
| Provider Information | |||||||||
| NPI: | 1467422469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRATIAS | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | ALEXANDRIA CLINIC | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207635123 | ||||||||
| FaxNumber: | 3207637883 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | ALEXANDRIA CLINIC | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207635123 | ||||||||
| FaxNumber: | 3207637883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 08/09/2013 | ||||||||
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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 | 363L00000X | R0721761 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 500001667 | 01 | MN | RR MEDICARE | OTHER | 408724100 | 05 | MN | MEDICAID |