Provider Demographics
NPI:1255300885
Name:WENTWORTH HARTUNG, NICOLE L (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:WENTWORTH HARTUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:WENTWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1700 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 FULTON ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-4800
Practice Address - Country:US
Practice Address - Phone:612-273-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43587207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN69B77WEOtherBLUE CROSS BLUE SHIELD MN
MN260472800Medicaid
MN3600166OtherMEDICA
WI34182800Medicaid
MN1027664OtherPREFERRED ONE
MN1383614OtherAMERICA'S PPO
MNHP33218OtherHEALTHPARTNERS
MN140263OtherUCARE MN
WI34182800Medicaid
MN69B77WEOtherBLUE CROSS BLUE SHIELD MN
WI34182800Medicaid