Provider Demographics
NPI:1598099772
Name:STILLWATER MEDICAL GROUP
Entity Type:Organization
Organization Name:STILLWATER MEDICAL GROUP
Other - Org Name:THE CLINIC AT WALMART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:NYBAKKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-275-3302
Mailing Address - Street 1:1500 CURVE CREST BLVD W
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6040
Mailing Address - Country:US
Mailing Address - Phone:651-439-1234
Mailing Address - Fax:651-275-3325
Practice Address - Street 1:5815 NORELL AVE N
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-1766
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:651-275-3325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN238363AM0700X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03865Medicare PIN