Basic Information
| Provider Information | |||||||||
| NPI: | 1790738003 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRY | ||||||||
| FirstName: | ANNE-MARIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 86 SDS 12 2901 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554862901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685050 | ||||||||
| FaxNumber: | 6519685900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SAINT JOHNS BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 03/12/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 10123 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 959415900 | 05 | MN | MEDICAID | 970002542 | 01 | MN | MEDICARE PROVIDER NUMBER | OTHER | P00302619 | 01 | MN | RAILROAD MEDICARE | OTHER |