Provider Demographics
NPI:1326076944
Name:JACOB, PREMA PADACHIRA (ANP)
Entity Type:Individual
Prefix:MRS
First Name:PREMA
Middle Name:PADACHIRA
Last Name:JACOB
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MS
Other - First Name:PREMA
Other - Middle Name:PADACHIRA
Other - Last Name:ABRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:9900 BREN RD E
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9664
Mailing Address - Country:US
Mailing Address - Phone:630-870-9660
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:630-870-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005523363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209005523Medicaid
ILQ66829Medicare UPIN