Provider Demographics
NPI:1649402512
Name:STANWAY, JILL M (PA-C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:STANWAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 METRO DR STE 460
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:651-999-6970
Practice Address - Street 1:6025 LAKE RD STE 200
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1710
Practice Address - Country:US
Practice Address - Phone:651-999-6800
Practice Address - Fax:833-905-0989
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11067363A00000X
WI2491363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical