Provider Demographics
NPI:1073568861
Name:VERCHOTA, GWEN MARIE (FNP)
Entity Type:Individual
Prefix:MS
First Name:GWEN
Middle Name:MARIE
Last Name:VERCHOTA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:M
Other - Last Name:VERCHOTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN-BC
Mailing Address - Street 1:51759 219TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-9357
Mailing Address - Country:US
Mailing Address - Phone:218-755-1994
Mailing Address - Fax:
Practice Address - Street 1:1500 BIRCHMONT DR. NE
Practice Address - Street 2:BEMIDJI STATE UNIVERSITY, STUDENT CENTER FOR HEALTH
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-2699
Practice Address - Country:US
Practice Address - Phone:218-755-2053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN30423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-03641OtherMN MEDICA
500014030OtherRAILROAD MEDICARE
MNHP28500OtherMN HEALTHPARTNERS
MN2527146-00Medicaid
MN52B87VEOtherMN BLUECROSS BLUESHIELD
MN01-03641OtherMN MEDICA
MNHP28500OtherMN HEALTHPARTNERS