Provider Demographics
NPI:1437106986
Name:KONSHOK, CLARICE HANKS (MD)
Entity Type:Individual
Prefix:
First Name:CLARICE
Middle Name:HANKS
Last Name:KONSHOK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CLARICE
Other - Middle Name:
Other - Last Name:HANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1555 NORTHWAY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4913
Mailing Address - Country:US
Mailing Address - Phone:320-240-3157
Mailing Address - Fax:320-240-3164
Practice Address - Street 1:1555 NORTHWAY DR STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4913
Practice Address - Country:US
Practice Address - Phone:320-240-3157
Practice Address - Fax:320-240-3164
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39535207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN064H2KOOtherMNBS #
MN064H3KOOtherMNBS #
MN2387955OtherAMERICA'S PPO/ARAZ #
MN18686Medicaid
MNDA9041045762OtherPREFERRED ONE #
MN064H1KOOtherMNBS #
MN0123278OtherMEDICA #
MN907913100Medicaid
MN2387955OtherAMERICA'S PPO/ARAZ #
MN18686Medicaid