Provider Demographics
NPI:1194205526
Name:BEAUDOIN, NICHOLAS DALE
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:DALE
Last Name:BEAUDOIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 E 26TH ST STE 600
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4515
Mailing Address - Country:US
Mailing Address - Phone:612-775-6200
Mailing Address - Fax:
Practice Address - Street 1:913 E 26TH ST STE 600
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-775-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant