Provider Demographics
NPI:1063483493
Name:THALACKER, MARK K (CNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:K
Last Name:THALACKER
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 WOODWINDS DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2298
Mailing Address - Country:US
Mailing Address - Phone:651-232-0500
Mailing Address - Fax:
Practice Address - Street 1:1875 WOODWINDS DR
Practice Address - Street 2:SUITE 130
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2298
Practice Address - Country:US
Practice Address - Phone:651-232-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR096321-5363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN815725100Medicaid
S71841Medicare UPIN
MN500009652Medicare ID - Type UnspecifiedRAILROAD
MN500000734Medicare ID - Type Unspecified