Provider Demographics
NPI:1235420670
Name:BJORE, NICHOLAS CAMERON (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:CAMERON
Last Name:BJORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5042
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:3580 ARCADE ST
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127-7135
Practice Address - Country:US
Practice Address - Phone:651-968-5200
Practice Address - Fax:651-968-5903
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11440363A00000X, 363AS0400X, 363A00000X
NDPAC0532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400124581Medicare PIN