Provider Demographics
NPI:1598866352
Name:MARCUCCIO, DOMINIC J (PA)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:J
Last Name:MARCUCCIO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 MARKETPOINTE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5435
Mailing Address - Country:US
Mailing Address - Phone:952-835-9880
Mailing Address - Fax:952-857-1554
Practice Address - Street 1:4300 MARKETPOINTE DR STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55435-5435
Practice Address - Country:US
Practice Address - Phone:952-835-9880
Practice Address - Fax:952-857-1554
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10548363A00000X
MDC0002706363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41953200Medicaid
WI41953200Medicaid
MDP89765Medicare UPIN
WI0133Medicare PIN
WI0068Medicare PIN