Basic Information
| Provider Information | |||||||||
| NPI: | 1598099772 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STILLWATER MEDICAL GROUP | ||||||||
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| OtherOrganizationName: | THE CLINIC AT WALMART | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 CURVE CREST BLVD W | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550826040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514391234 | ||||||||
| FaxNumber: | 6512753325 | ||||||||
| Practice Location | |||||||||
| Address1: | 5815 NORELL AVE N | ||||||||
| Address2: | |||||||||
| City: | OAK PARK HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550821766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514391234 | ||||||||
| FaxNumber: | 6512753325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2009 | ||||||||
| LastUpdateDate: | 01/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | NYBAKKEN | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6512753302 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 238 | MN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363LA2100X | 238 | MN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.