Basic Information
| Provider Information | |||||||||
| NPI: | 1487607172 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAHL | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 FOURTH AVE SE | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563341820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206344521 | ||||||||
| FaxNumber: | 3206342244 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ELM ST N | ||||||||
| Address2: | |||||||||
| City: | ONAMIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563597901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205323154 | ||||||||
| FaxNumber: | 3205323111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 12/09/2015 | ||||||||
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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 | 363AM0700X | 9574 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | NA9091026947 | 01 | MN | PREFERRED ONE | OTHER | 258696700 | 05 | MN | MEDICAID |