Provider Demographics
NPI:1356486963
Name:GOEMBEL, JESSE L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:L
Last Name:GOEMBEL
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 1:550 OSBORNE RD NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2718
Mailing Address - Country:US
Mailing Address - Phone:763-236-5000
Mailing Address - Fax:763-236-3516
Practice Address - Street 1:550 OSBORNE RD NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2718
Practice Address - Country:US
Practice Address - Phone:763-236-5000
Practice Address - Fax:763-236-3516
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0643363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1238OtherMN TEMPORARY LICENSE
SD6829150Medicaid
SD0643OtherSTATE LICENSE
SDQ78188Medicare UPIN
SD6829150Medicaid