Basic Information
| Provider Information | |||||||||
| NPI: | 1598946568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHITU | ||||||||
| FirstName: | IOAN | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | I | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHITU | ||||||||
| OtherFirstName: | JOHN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 323 S MINNESOTA ST | ||||||||
| Address2: | |||||||||
| City: | CROOKSTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567161601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182819553 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 323 S MINNESOTA ST | ||||||||
| Address2: | |||||||||
| City: | CROOKSTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567161601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182819553 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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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 | 10322 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 10322 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 10322 | 01 | MN | PA CERTIFICATION | OTHER | PAC0379 | 01 | ND | PA LICENSE | OTHER |