Basic Information
| Provider Information | |||||||||
| NPI: | 1689653685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NACK | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1230 E MAIN ST | ||||||||
| Address2: | PO BOX 8674 | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1421 PREMIER DR | ||||||||
| Address2: | MANKATO CLINIC @ WICKERSHAM CAMPUS | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 467 | MN | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 480018348 | 01 | RR MEDICARE | OTHER | 115548 | 01 | MN | UCARE | OTHER | 2700675 | 01 | MN | MEDICA | OTHER | 334225500 | 05 | MN | MEDICAID | 938225 | 05 | IA | MEDICAID | HP26034 | 01 | MN | HEALTH PARTNERS | OTHER | NA2951014382 | 01 | MN | PREFERRED ONE | OTHER | 0M249NA | 01 | MN | BCBA | OTHER | 41084933956001C040 | 01 | CHAMPUS | OTHER | 766559 | 01 | MN | AMERICAS PPO | OTHER |