Provider Demographics
NPI:1073589123
Name:EGGERS, JENNIFER RAE (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:EGGERS
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
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Other - Credentials:
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 1:5100 GAMBLE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1521
Practice Address - Country:US
Practice Address - Phone:952-541-2500
Practice Address - Fax:952-541-2626
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2014-04-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN10080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q59241Medicare UPIN
970002434Medicare ID - Type Unspecified