Basic Information
| Provider Information | |||||||||
| NPI: | 1669451688 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SWANSON | ||||||||
| FirstName: | PENELOPE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8674 | ||||||||
| Address2: | 1230 E MAIN ST | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1421 PREMIER DR | ||||||||
| Address2: | |||||||||
| City: | MANAKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 44271 | MN | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 2409708 | 01 | AMERICAS PPO MN | OTHER | 41084933956001G010 | 01 | CHAMPUS | OTHER | NA2951040749 | 01 | PREFERRED ONE MN | OTHER | 796S7SW | 01 | BCBS MN | OTHER | 0801074 | 01 | MEDICA MN | OTHER | 448032500 | 05 | MN | MEDICAID | HP41128 | 01 | HEALTH PARTNERS MN | OTHER | 166247 | 01 | UCARE MN | OTHER | 0586008 | 05 | IA | MEDICAID | P00144651 | 01 | RR MEDICARE | OTHER |