Provider Demographics
NPI:1083659122
Name:SHORT, GWENDOLYN (ARNP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 20TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-4400
Mailing Address - Country:US
Mailing Address - Phone:612-332-4973
Mailing Address - Fax:
Practice Address - Street 1:142 E. DEARBORN
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:OR
Practice Address - Zip Code:97883-0986
Practice Address - Country:US
Practice Address - Phone:541-562-6062
Practice Address - Fax:541-562-5757
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200750114NP FNP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR139449Medicaid
200750114NP FNP-PPOtherOSBN LICENSURE
ORMS1631894OtherDEA REGISTRATION NUMBER