Provider Demographics
NPI:1568437879
Name:DZIEDZIC, KELLY L (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:DZIEDZIC
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5042
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:1000 W 140TH ST UNIT 201
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4833
Practice Address - Country:US
Practice Address - Phone:952-808-3000
Practice Address - Fax:952-808-3001
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2019-01-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN9792363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN205559700Medicaid
MN205559700Medicaid