Provider Demographics
NPI:1033176862
Name:PICKENS, ANNEMARIE A (PA)
Entity Type:Individual
Prefix:
First Name:ANNEMARIE
Middle Name:A
Last Name:PICKENS
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:MC21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7172
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:3930 NORTHWOODS DR
Practice Address - Street 2:MAIL STOP 32800A
Practice Address - City:ARDEN HILLS
Practice Address - State:MN
Practice Address - Zip Code:55112-6974
Practice Address - Country:US
Practice Address - Phone:651-490-6700
Practice Address - Fax:651-490-6730
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2021-03-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN9962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN847923200Medicaid
970002290Medicare ID - Type Unspecified
MN847923200Medicaid