Provider Demographics
NPI:1487647996
Name:PLACKNER, BRENT D (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:D
Last Name:PLACKNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2277 HIGHWAY 36 W STE 140
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3895
Mailing Address - Country:US
Mailing Address - Phone:612-255-0628
Mailing Address - Fax:612-255-0647
Practice Address - Street 1:970 PICKETT ST N
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:MN
Practice Address - Zip Code:55003-1489
Practice Address - Country:US
Practice Address - Phone:651-779-5713
Practice Address - Fax:651-747-1621
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI865-23363A00000X
MN11906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI004156125OtherMEDICARE NUMBER
WI42958400Medicaid
WI42958400Medicaid