Provider Demographics
NPI:1104932748
Name:VAUGHAN, SOMMER NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:SOMMER
Middle Name:NICOLE
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4200 DAHLBERG DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4840
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:952-512-5651
Practice Address - Street 1:560 S MAPLE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1733
Practice Address - Country:US
Practice Address - Phone:952-442-2163
Practice Address - Fax:952-442-5903
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
969991035001OtherPREFERREDONE
114950OtherMEDICA
HP39234OtherHEALTHPARTNERS
P96936Medicare UPIN
336R2VAOtherBLUECROSS BLUESHIELD