Basic Information
| Provider Information | |||||||||
| NPI: | 1992796841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANG | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1520 NORTHWAY COURT | ||||||||
| Address2: | CENTRACARE CLINIC HEARTLAND | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202511775 | ||||||||
| FaxNumber: | 3202403131 | ||||||||
| Practice Location | |||||||||
| Address1: | 1520 NORTHWAY COURT | ||||||||
| Address2: | CENTRACARE CLINIC HEARTLAND | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202511775 | ||||||||
| FaxNumber: | 3202403131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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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 | 363LA2200X | R1237351 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 002219500 | 01 | MEDICAL ASSISTANCE | OTHER | 1014181 | 01 | PREFERRED ONE | OTHER | 86D79ST | 01 | BLUE CROSS BLUE SHIELD | OTHER | HP23116 | 01 | HEALTH PARTNERS | OTHER | R1237351 | 01 | MN LICENSE NUMBER | OTHER | MS0300260 | 01 | DEA | OTHER | 0110555 | 01 | MEDICA HEALTH PLANS | OTHER | 122925 | 01 | U CARE | OTHER |