Provider Demographics
NPI:1407968084
Name:COUSINS, DANA B (PAC)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:B
Last Name:COUSINS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:B
Other - Last Name:KIRKEMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:909 FULTON ST SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-4800
Mailing Address - Country:US
Mailing Address - Phone:612-672-7422
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:612-672-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
007T5K1OtherBLUE CROSS BLUE SHIELD
1018609OtherPREFERRED ONE
140233OtherUCARE MINNESOTA
WI41920500Medicaid
0114474OtherMEDICA
0874868OtherAMERICAN PPO
MN180172400Medicaid
WI41920500Medicaid
WI41920500Medicaid