Provider Demographics
NPI:1447560693
Name:EDSTROM, JEANINE MARIE (PAC)
Entity Type:Individual
Prefix:MS
First Name:JEANINE
Middle Name:MARIE
Last Name:EDSTROM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JEANINE
Other - Middle Name:MARIE
Other - Last Name:WORMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 14909
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-0909
Mailing Address - Country:US
Mailing Address - Phone:612-871-1145
Mailing Address - Fax:612-870-5491
Practice Address - Street 1:1185 TOWN CENTRE DR STE 200
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1343
Practice Address - Country:US
Practice Address - Phone:612-871-1145
Practice Address - Fax:612-870-5491
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1504363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical