Provider Demographics
NPI:1033139910
Name:SHIELDS, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 W BROADWAY AVE
Mailing Address - Street 2:SUITE 601
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-1923
Mailing Address - Country:US
Mailing Address - Phone:763-587-7900
Mailing Address - Fax:763-587-7069
Practice Address - Street 1:3366 OAKDALE AVE N
Practice Address - Street 2:SUITE 551
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2948
Practice Address - Country:US
Practice Address - Phone:763-587-7737
Practice Address - Fax:763-587-7069
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR0790556363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN698517300Medicaid
R90622Medicare UPIN