Basic Information
| Provider Information | |||||||||
| NPI: | 1891769592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIELDS | ||||||||
| FirstName: | JOAN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 ELM ST N | ||||||||
| Address2: | |||||||||
| City: | ONAMIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563597901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205323154 | ||||||||
| FaxNumber: | 3205323111 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ELM ST N | ||||||||
| Address2: | |||||||||
| City: | ONAMIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563597901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205323154 | ||||||||
| FaxNumber: | 3205323111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 09/05/2014 | ||||||||
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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 | 9051 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 01-13466 | 01 | MN | MEDICA ISLE | OTHER | HP20623 | 01 | MN | HEALTH PARTNERS | OTHER | 01-13465 | 01 | MN | MEDICA HILLMAN | OTHER | 18358 | 01 | ND | MEDICAID | OTHER | 831785200 | 05 | MN | MEDICAID | 485T0SH | 01 | MN | BLUE CROSS CLINIC | OTHER | NA9091004444 | 01 | MN | PREFERED ONE | OTHER | 01-13458 | 01 | MN | MEDICA ONAMIA CLINIC | OTHER | 06F16SH | 01 | MN | BLUE CROSS HOSPITAL | OTHER | 115811 | 01 | MN | UCARE | OTHER |