Provider Demographics
NPI:1295196285
Name:MARCELLINO, NIKKI L (PA)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:L
Last Name:MARCELLINO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8450 SEASONS PKWY
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4402
Practice Address - Country:US
Practice Address - Phone:651-702-5300
Practice Address - Fax:651-702-5305
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN12035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant